4.6.0.0 Pre-‍ex­er­cise Eval­u­a­tion

As dis­cussed more fully in Sec­tion 10 “Car­dio­vas­cu­lar Dis­ease and Risk Man­age­ment,” the best pro­to­col for as­sessing asymp­tomat­ic pa­tients with di­a­betes for coro­nary artery dis­ease re­mains un­clear. The ADA con­sen­sus re­port “Screen­ing for Coro­nary Artery Dis­ease in Pa­tients With Di­a­betes” (156) con­clud­ed that rou­tine test­ing is not rec­om­mend­ed. How­ev­er, pro­viders should per­form a care­ful his­to­ry, as­sess car­dio­vas­cu­lar risk fac­tors, and be aware of the atyp­i­cal pre­sen­ta­tion of coro­nary artery dis­ease in pa­tients with di­a­betes. Cer­tain­ly, high-‍risk pa­tients should be en­cour­aged to start with short pe­ri­ods of low-‍in­ten­si­ty ex­er­cise and slow­ly in­crease the in­ten­si­ty and du­ra­tion as tol­er­at­ed. Providers should as­sess pa­tients for con­di­tions that might contrain­di­cate cer­tain types of ex­er­cise or pre­dis­pose to in­jury, such as uncon­trolled hy­per­ten­sion, un­treat­ed pro­lif­er­a­tive retinopa­thy, au­to­nom­ic neu­ropa­thy, pe­riph­er­al neu­ropa­thy, and a his­to­ry of foot ul­cers or Char­cot foot. The pa­tient’s age and pre­vi­ous phys­i­cal ac­tiv­i­ty level should be con­sid­ered. The pro­vider should cus­tomize the ex­er­cise reg­i­men to the in­di­vid­u­al’s needs. Those with com­pli­ca­tions may re­quire a more thor­ough eval­u­a­tion prior to be­gin­ning an ex­er­cise pro­gram (138).