This document provides guidance from a cardiologist on various questions that diabetologists may have regarding their patients. It recommends obtaining an ECG for all diabetic patients on diagnosis and follow-up. It provides guidance on when to refer to a cardiologist based on symptoms like palor, elevated JVP, hypertension, abnormal pulse, pedal swelling, or cardiac sounds. It discusses evaluating chest pain and breathlessness and the tests that may be needed. It also provides guidance on heart failure management in diabetic patients, use of aspirin and statins, selecting antihypertensives and antidiabetic medications, and when to advise coronary angiography.

1. Cardiology Opinion
for Diabetic patients
Dr. Dibbendhu Khanra
DM Cardiology
Interventional Cardiologist
AIIMS, Rishikesh

2. What do diabetologists want to know?
• When to refer to cardiologist?
• Is the chest pain serious?
• Is the breathlessness serious?
• Any abnormality in ECG?
• Is echo to be done?
• Should aspirin be given?
• Should statin be given?
• Which antihypertensive to start with?
• Which antidiabetic is best?
• When to advise for coronary angiogrpahy?

3. When to refer to cardiologist?
• All patients of diabetis on diagnosis and follow-up
• Pallor - CKD
• JVP – elevated in HFpEF
• BP - HTN
• Pulse – AF
• Pedal swelling – HFpEF
• CVS – S3, S4
• ECG in all

4. Is the chest pain serious?
• Pain in precordium
• Quality is exertional
• Radiation
• Sweating/ sorbitrate/ smoker
• Temporal >20mins
ECG needed!

5. Is the breathlessness serious?
• HTN
• Elderly
• OSA
• Exertional SOB
• More pillows/ PND
• Pedal swelling
May be HFpEF/ NT proBNP, ECHO

6. Heart failure and diabetis!
• HFrEF: SGLT2i/ ARNI
• HFpEF: ARNI?
• ‘Diab CMP’: SGLT2i
• LBBB/ Broad QRS: CRT
• Non LBBB: HBP
• Afib: NOAC (P-CHA2S2VASC)
• AF + HFrEF=RFA (CABANA)

7. Any abnormality in ECG?
• All patients of diabetis
• Separate discussion for that!
• Ischemia
• Failure

8. Is echo to be done?
• Not in all
• Typical angina (RWMA)
• SOB (HFpEF)
• ECG changes (RWMA)
• Old MI (EF)
• CVS – murmer (MR)

9. Should aspirin be given?
• ASPIRIN does not protect!
• ASPREE, ARRIVE, ASCEND
• Only if evidence of CAD
• Typical angina/ ECG changes/ Echo changes
• If to be given dose 75 mg
• ONLY ASPIRIN NOT CLOPIDEGROL
• Post stent, 150 mg can be given

10. Should statin be given?
• DM == atheroscletic disease
• Statin is to be given in all
• Rosuvastatin = atorvastatin// 40mg OK
• New onset diabetis! (MetS, Hbaic>6, hscrp>2)
• Target: LDL <70 (post ACS), LDL <100 (CAD)
• TG more!..statin only, IMPROVE IT = Eztemibe
• Saroglitazar (LIPAGLYN)
• Lp (a)/ non HDL cholesterol

11. Statin pathway

12. Which antihypertensive to start with?
• ACEI (post MI)/ ARB (otherwise)

13. Blood pressure targets

14. HTN pathway

15. Which anti-diabetic is best?

16. EMPAREG
EMPAHEART
DECLARE
DELIGHT
CANVAS
CRESDENCE
UTI
DKA
K
#
Creat
PAD

17. When to advise for coronary angiography?
• Class III angina
• ECG changes/ TMT +ve
• CT angio: Prox LAD dis
• OMT failied
• Nuclear scan
• REMEMBER ORBITA!
• FORGET COURAGE/ BARI
• DAPT more than one year

18. Summary
• ECG for all
• Echo selective
• Statin for all
• Aspirin selective
• Stents does not prevent death/ angina always
• ARB/ CTD/ Spiranolcatone
• HFpEF
• Afib
• SGLTi
• ARNI

19. Questions?