So…. the whole commenting thing didn’t work out so well. I choose to believe that many tried and failed, rather than that I’m talking to myself over here. So, here’s my take on our case. Disagree? Something to add? Speak up on Twitter (follow @ihaterashes)
You have a 58 year old white male patient who you’ve seen 4-5 times in your continuity clinic. He has diabetes (uncontrolled, with HbA1c 9.5%), HTN (typically reads low 150s/90s in clinic), and hyperlipidemia (guess what? He refuses medicines). Oh, and his BMI is 36.
You’ve been harping on the miraculous benefits of diet and exercise all this time, and he’s finally decided to give it a try. He tells you that he’s joined Crossfit and is ready to start exercising, once you give the OK.
Does he need some testing before you give the “OK”? The commercials say, “Talk to your doctor before starting an exercise program.” So what are we supposed to say or do?
For low/average risk patients there is no benefit to screening for asymptomatic coronary disease. The ACC has added stress testing in asymptomatic individuals to their list of tests to avoid in the ABIM’s Choosing Wisely Initiative.
But our patient has diabetes, so he’s not low risk. Not only that, but he has uncontrolled hypertension and hyperlipidemia, so he most certainly has as much risk for a cardiac event as someone who has had an MI. In fact, if you follow the Choosing Wisely link above, you note there is a caveat for patients with diabetes over age 40. So, should we screen him?
Some guideline writers, including the American College of Cardiology, recommend stress testing in asymptomatic diabetics over 40. The ADA says that EKG exercise testing may be indicated for those diabetics starting an exercise program if: they are over 40, over 30 with signs of advanced diabetes (nephropathy, retinopathy), smokers, or have renal failure due to their diabetes.
So the guideline writers would screen our patient. Here’s my concern though, what are we going to do with the information? He already needs aggressive medical therapy (which he’s not really getting). Perhaps we would do best to just focus on that. Should we revascularize if significant ischemia is found?
There was one trial, DIAD, which randomized 1123 asymptomatic diabetic patients to screening with adenosine MIBI vs no screening. These patients were largely well controlled with aggressive medical management, and the overall cardiac event rate was only 3% for the whole group. There was no difference in the screened and unscreened groups, however, our patient is so uncontrolled on all risk factors, I’m not sure he fits in. Our pre-test probability of coronary disease is likely higher than 3%, even without symptoms.
What about the exercise itself? I’ve not done CrossFit myself, but it looks fairly intense, with a lot of callisthenic type exercises done fast enough to get an aerobic benefit. I would be afraid that if he jumped right into an intense “boot camp” like experience like CrossFit, that he might injure himself and then quit exercise all together. It is a tricky thing to encourage exercise, but in such a way that it is more likely to stick as a lifestyle change, rather than a month or so of intermittent involvement that quickly fades away.
So, I would probably applaud him for his initiative, but ask him to take it a little easy and work on a simple paced exercise program to start. I would ask a lot of questions to convince myself that he really is asymptomatic, and have a very low threshold for getting stress testing (ideally with exercise MIBI). You could refer him to cardiopulmonary rehab, so that he could get close monitoring of his HR and BP during exercise (assuming he could pay for it- insurance likely will not). At the same time, he needs to get his risk factors under control– start a statin, titrate his HTN and diabetic medicines. Certainly give him clear warnings of angina or even anginal equivalents that he might experience, with direction to stop if he does.
Thanks to all for the patience with my blog issues. New site is coming soon, hopefully with fewer technical difficulties!