Guidelines for Exercise Testing in Diabetics Starting an Exercise Program

Abstract

Because diabetes mellitus is considered a major risk factor for cardiovascular disease, the clinical evaluation of the patient with diabetes is an assessment performed by primary care and specialty physicians on a daily basis. A careful history, medical record review, current treatment (oral agents, insulin), related comorbidities (hypertension, obesity, metabolic syndrome, coronary artery disease), electrocardiogram (ECG), laboratory studies (blood glucose, hemoglobin A1c, serum creatinine, estimated glomerular filtration rate, urine albumin/creatinine ratio), ankle/brachial systolic pressure index, and exercise stress test may be important components of this evaluation. In addition to the indications and contraindications and appropriate methodology (protocols) for exercise testing, key diagnostic and prognostic variables include: the resting and exercise ECG, especially the provocation of significant ST-segment displacement and/or arrhythmias during or after exercise testing; anginal symptoms; dyspnea; chronotropic incompetence; abnormal heart rate recovery; exertional hyper or hypotension; exercise capacity, expressed as metabolic equivalents (METs; 1 MET = 3.5 mL/kg/min); and combined information (e.g., treadmill scores [Duke Treadmill Score]). Echocardiographic studies may also reveal impaired left ventricular diastolic function, a condition that is common in diabetes, which often precedes systolic dysfunction. Collectively, these data should prove helpful in prescribing exercise and identifying treatment targets to prevent end-organ complications and major cardiovascular events in this escalating patient population.