Guidelines for Exercise Testing in Diabetics Starting an Exercise Program

  • Barry A. Franklin
  • Wendy M. Miller
  • Katherine Nori
  • Peter A. McCullough
Part of the Contemporary Diabetes book series (CDI)


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.


Diabetes Exercise testing Exercise capacity Evaluation of patients with diabetes mellitus 


  1. 1.
    Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560–2572.PubMedCrossRefGoogle Scholar
  2. 2.
    Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina – summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Chronic Stable Angina). Circulation 2003;107:149–158.PubMedCrossRefGoogle Scholar
  3. 3.
    Stewart KJ. Exercise training for claudication. N Engl J Med 2002;347:1941–1951.PubMedCrossRefGoogle Scholar
  4. 4.
    Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;13;110:227–239.CrossRefGoogle Scholar
  5. 5.
    Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002;106:1883–1892.PubMedCrossRefGoogle Scholar
  6. 6.
    Beaver WL, Wasserman K, Whipp BJ. A new method for detecting the anaerobic threshold by gas exchange. J Appl Physiol 1986;60:2020–2027.PubMedGoogle Scholar
  7. 7.
    Corrà U, Mezzani A, Bosimini E, Scapellato F, Imparato A, Giannuzzi P. Ventilatory response to exercise improves risk stratification in patients with chronic heart failure and intermediate functional capacity. Am Heart J 2002;143:18–26.CrossRefGoogle Scholar
  8. 8.
    American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2002;25:S33–S49.CrossRefGoogle Scholar
  9. 9.
    Barrett EJ, Ginsberg HN, Pauker SG, et al. Consensus Development Conference on the Diagnosis of Coronary Heart Disease in People with Diabetes: 10–11 February 1998, Miami, Florida. Diabetes Care 1998;21:1551–1559.CrossRefGoogle Scholar
  10. 10.
    Kannel WB, D'Agostino RB, Wilson PW, Belanger AJ, Gagnon DR. Diabetes, fibrinogen, and risk of cardiovascular disease: the Framingham experience. Am Heart J 1990;120:672–676.PubMedCrossRefGoogle Scholar
  11. 11.
    American Diabetes Association. Economic consequences of diabetes mellitus in the U.S. in 1997. Diabetes Care 1998;21:296–309.CrossRefGoogle Scholar
  12. 12.
    Inzucchi SE. Noninvasive assessment of the diabetic patient for coronary artery disease. Diabetes Care 2001;24:1519–1521.PubMedCrossRefGoogle Scholar
  13. 13.
    Zinman B, Ruderman N, Campaigne BN, Devlin JT, Schneider SH. American Diabetes Association. Physical activity/exercise and diabetes mellitus (position statement). Diabetes Care 2003;26 (Suppl 1):S73–S77.PubMedGoogle Scholar
  14. 14.
    Wackers FJTh, Young LH, Inzucchi SE, et al. Detection of silent myocardial ischemia in asymptomatic diabetic subjects. The DIAD study. Diabetes Care 2004;27:2954–2961.CrossRefGoogle Scholar
  15. 15.
    Scognamiglio R, Negut C, Ramondo A, Tiengo A, Avogaro A. Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus. J Am Coll Cardiol 2006;47:65–71.PubMedCrossRefGoogle Scholar
  16. 16.
    American College of Sports Medicine. Guidelines for Exercise Testing and Prescription, 7th ed. Baltimore, MD: Lippincott Williams & Wilkins, 2005.Google Scholar
  17. 17.
    Fowler-Brown A, Pignone M, Pletcher M, Tice JA, Sutton SF, Lohr KN. Exercise tolerance testing to screen for coronary heart disease: a systematic review for the technical support for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:W9–W24.PubMedGoogle Scholar
  18. 18.
    U.S. Preventive Services Task Force. Screening for coronary heart disease: recommendation statement. Ann Intern Med 2004;140:569–572.Google Scholar
  19. 19.
    Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C. Physical activity/exercise and type 2 diabetes. Diabetes Care 2004;27:2518–2539.PubMedCrossRefGoogle Scholar
  20. 20.
    Falk E, Shah PK, Fuster V. Coronary plaque disruption. Circulation 1995;92:657–671.PubMedGoogle Scholar
  21. 21.
    Malinow MR, McGarry DL, Kuehl KS. Is exercise testing indicated for asymptomatic active people? J Cardiac Rehabil 1984;4:376–380.Google Scholar
  22. 22.
    Franklin BA, Gordon NF. Contemporary Diagnosis and Management in Cardiovascular Exercise. Newtown, PA: Handbooks in Health Care, 2005.Google Scholar
  23. 23.
    Gibbons RA, Balady GJ, Beasely JW, et al. ACC/AHA guidelines for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol 1997;30:260–315.PubMedCrossRefGoogle Scholar
  24. 24.
    Franklin BA. Exercise testing, training and arm ergometry. Sports Med 1985;2:100–119.PubMedCrossRefGoogle Scholar
  25. 25.
    American College of Sports Medicine. Guidelines for Exercise Testing and Prescription, 4th ed. Philadelphia, PA: Lea & Febiger, 1991:61.Google Scholar
  26. 26.
    Myers J, Buchanan N, Walsh D, et al. Comparison of the ramp versus standard exercise protocols. J Am Coll Cardiol 1991;17:1334–1342.PubMedCrossRefGoogle Scholar
  27. 27.
    Hesse B, Diaz LA, Snader CE, Blackstone EH, Lauer MS. Complete bundle branch block as an independent predictor of all-cause mortality: report of 7073 patients referred for nuclear exercise testing. Am J Med 2001;110:253–259.PubMedCrossRefGoogle Scholar
  28. 28.
    Nostratian F, Froelicher VF. ST elevation during exercise testing. Am J Cardiol 1989;63:986–988.CrossRefGoogle Scholar
  29. 29.
    Wackers FJTh, Zaret BL. Detection of myocardial ischemia in patients with diabetes mellitus. Circulation 2002;105:5–7.PubMedGoogle Scholar
  30. 30.
    Kamalesh M, Feigenbaum H, Sawada S. Challenge of identifying patients with diabetes mellitus who are at low risk for coronary events by use of cardiac stress imaging. Am Heart J 2004;147:561–563.PubMedCrossRefGoogle Scholar
  31. 31.
    Wackers FJTh. Diabetes and coronary artery disease: The role of stress myocardial perfusion imaging. Cleve Clin J Med 2005;72:21–33.PubMedCrossRefGoogle Scholar
  32. 32.
    Lauer MS. Coronary artery disease in diabetes: which (if any) test is best. Cleve Clin J Med 2005;72:6–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Jouven X, Zuriek M, Desnos M, Courbon D, Ducimetière P. Long-term outcome in asymptomatic men with exercise-induced premature ventricular depolarizations. N Engl J Med 2000;343:826–833.PubMedCrossRefGoogle Scholar
  34. 34.
    Frolkis JP, Pothier CE, Blackstone EH, Lauer MS. Frequent ventricular ectopy after exercise as a predictor of death. N Engl J Med 2003;348:781–790.PubMedCrossRefGoogle Scholar
  35. 35.
    Cole JP, Ellestad MH. Significance of chest pain during treadmill exercise: correlation with coronary events. Am J Cardiol 1978;41:227–232.PubMedCrossRefGoogle Scholar
  36. 36.
    Abidov A, Rozanski A, Hachamovitch R, et al. Prognostic significance of dyspnea in patients referred for cardiac stress testing. N Engl J Med 2005;353:1889–1898.PubMedCrossRefGoogle Scholar
  37. 37.
    Brener SJ, Pashkow FJ, Harvey SA, Marwick TH, Thomas JD, Lauer MS. Chronotropic response to exercise predicts angiographic severity in patients with suspected or stable coronary artery disease. Am J Cardiol 1995;76:1228–1232.PubMedCrossRefGoogle Scholar
  38. 38.
    Lauer MS, Francis GS, Okin PM, Pashkow FJ, Snader CE, Marwick TH. Impaired chronotropic response to exercise stress testing as a predictor of mortality. JAMA 1999;281:524–529.PubMedCrossRefGoogle Scholar
  39. 39.
    Vivekananthan DP, Blackstone EH, Pothier CE, Lauer MS. Heart rate recovery after exercise is a predictor of mortality, independent of the angiographic severity of coronary disease. J Am Coll Cardiol 2003;42:831–838.PubMedCrossRefGoogle Scholar
  40. 40.
    Cole CR, Blackstone EH, Pashkow FJ, Snader CE, Lauer MS. Heart-rate recovery immediately after exercise as a predictor of mortality. N Engl J Med 1999;341:1351–1357.PubMedCrossRefGoogle Scholar
  41. 41.
    Cheng YJ, Lauer MS, Earnest CP, et al. Heart rate recovery following maximal exercise testing as a predictor of cardiovascular disease and all-cause mortality in men with diabetes. Diabetes Care 2003;26:2052–2057.PubMedCrossRefGoogle Scholar
  42. 42.
    Jouven X, Empana J-P, Schwartz PJ, Desnos M, Courbon D, Ducimetière P. Heart-rate profile during exercise as a predictor of sudden death. N Engl J Med 2005;352:1951–1958.PubMedCrossRefGoogle Scholar
  43. 43.
    Irving JB, Bruce RA, DeRouen TA. Variations in and significance of systolic pressure during maximal exercise (treadmill) testing: relation to severity of coronary artery disease and cardiac mortality. Am J Cardiol 1977;39:841–848.PubMedCrossRefGoogle Scholar
  44. 44.
    Sheps DS, Ernst JC, Briese FW, Myerburg RJ. Exercise-induced increase in diastolic pressure: indicator of severe coronary artery disease. Am J Cardiol 1979;43:708–712.PubMedCrossRefGoogle Scholar
  45. 45.
    Snader CE, Marwick TH, Pashkow FJ, Harvey SA, Thomas JD, Lauer MS. Importance of estimated functional capacity as a predictor of all-cause mortality among patients referred for exercise thallium single-photon emission computed tomography: Report of 3,400 patients from a single center. J Am Coll Cardiol 1997;30:641–648.PubMedCrossRefGoogle Scholar
  46. 46.
    Dutcher JR, Kahn J, Grines C, Franklin B. Comparison of left ventricular ejection fraction and exercise capacity as predictors of two- and five-year mortality following acute myocardial infarction. Am J Cardiol 2007;99:436–441.PubMedCrossRefGoogle Scholar
  47. 47.
    Wei M, Gibbons LW, Mitchell TL, Kampert JB, Lee CD, Blair SN. The association between cardiorespiratory fitness and impaired fasting glucose and type 2 diabetes mellitus in men. Ann Intern Med 1999;130:89–96.PubMedGoogle Scholar
  48. 48.
    Church TS, Cheng YJ, Earnest CP, et al. Exercise capacity and body composition as predictors of mortality among men with diabetes. Diabetes Care 2004;27:83–88.PubMedCrossRefGoogle Scholar
  49. 49.
    Mark DB, Hlatky MA, Harrell FE, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med 1987;106:793–800.PubMedGoogle Scholar
  50. 50.
    Mark DB, Shaw L, Harrell FE, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 1991;325:849–853.PubMedCrossRefGoogle Scholar
  51. 51.
    Shaw LJ, Peterson ED, Shaw LK, et al. Use of prognostic treadmill score in identifying diagnostic coronary disease subgroups. Circulation 1998;98:1622–1630.PubMedGoogle Scholar
  52. 52.
    Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training. A statement for Healthcare Professionals from the American Heart Association. Circulation 2001;104:1694–1740.PubMedCrossRefGoogle Scholar
  53. 53.
    Lakkireddy DR, Bhakkad J, Korlakunta HL, et al. Prognostic value of the Duke treadmill score in diabetic patients. Am Heart J 2005;150:516–521.PubMedCrossRefGoogle Scholar

Copyright information

© Humana Press, a part of Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Barry A. Franklin
    • 1
  • Wendy M. Miller
    • 2
  • Katherine Nori
    • 3
  • Peter A. McCullough
    • 2
  1. 1.Division of CardiologyCardiac Rehabilitation/Exercise Laboratories, William Beaumont HospitalRoyal OakUSA
  2. 2.Division of Nutrition and Preventive MedicineDepartment of Medicine, William Beaumont HospitalRoyal OakUSA
  3. 3.Beaumont Health Center, Weight Control CenterDivision of Nutrition and Preventive Medicine, William Beaumont HospitalRoyal OakUSA

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