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May 2019, Volume 69, Issue 5

Primary Care Diabetes

Anginal Equivalents: As simple as ABCDE

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Kamal Kishor  ( Department of Endocrinology, Bharti Hospital, Karnal, India )


This communication highlights the concept of angina  equivalents as an important symptom of cardiovasculardisease in diabetes. The authors share two mnemonics, as simple as ABCDE, which can help identify atypical cardiovascular disease. Use of these learning tools should help improve early detection and management of cardiovascular disease.

Keywords: Angina, acute coronary syndrome, coronary artery disease, diabetes.


Cardiovascular disease (CVD) is a common complication of diabetes, and it is a major contributor to premature mortality in a person with diabetes. Much of the burden of CVD can be minimized if it is detected and prevented in time1. Current standards of care do not recommend routine invasive or stress based diagnostic modalities to diagnose underlying CVD in asymptomatic persons with diabetes  mellitus2. This is because of a skewed risk benefit ratio. This means that the detection of CVD or institution of preventive pharmacotherapy (such as statins) is based upon clinical parameters. While history taking and physical examination are an important and indispensable part of clinical medicine, they are quite subjective and person dependent. This means that the chances of misdiagnosis (both under and over identification) of CVD may be significant. In recent years, evidence based risk stratification tools have been developed to assess CVD risk, and validated scoring systems are available to screen for heart failure 3-5. These have helped bring objectivity to the clinical assessment of CVD.


However, there is a significant proportion of persons with diabetes and CVD, who do not present with overt or classic symptomatology of angina. Due to multiple reasons, including autonomic neuropathy and transient congestive cardiac failure, persons with diabetes may suffer from ‘silent‘ myocardial infarction 6,7. Such persons do not report typical chest pain or discomfort which worsens on exertion. However, detailed questioning reveals subtle clues which suggest CVD.


Such historical clues are known as anginal equivalents. Stern et al have8 evocatively described these as ‘the sounds of silence’. Included in the list are dyspnoea, palpitations, fatigue, erectile dysfunction and and genetics (family history). In fact, isolated typical angina pain is found in a minority of patients with ST segment deviation, with the most common symptom being dyspnoea9. Involvement of other vascular beds, as inerectile dysfunction, is also known to be an indicator of CVD in diabetes10,11. We share two simple mnemonics, meant to simplify angina equivalents in acute as well as chronic settings (Table 1, 2).

Both aim to make identification of CVD equivalents as simple as ABCDE. We appreciate that the symptoms and conditions listed here are not specific to CVD, and that they may have unrelated etiologies. The rubrics are not validated scoring systems or means for risk stratification, either. However, we share them as learning tools, and as aids to improve clinical assessment of persons with potential CVD.


1. Misra A, Tandon N, Ebrahim S, Sattar N, Alam D, Shrivastava U, et al. Diabetes, cardiovascular disease, and chronic kidney disease in South Asia: current status and future directions. BMJ: British Medical Journal (Online). 2017;357.
2. Bajaj S. RSSDI clinical practice recommendations for the management of type 2 diabetes mellitus 2017. Int J Diabetes Dev Ctries.2018;38:1-15.
3. Lloyd-Jones DM, Wilson PW, Larson MG, Beiser A, Leip EP, D'Agostino RB, et al. Framingham risk score and prediction of lifetime risk for coronary heart disease. Am J Cardiol. 2004;94:20-4.
4. Olesen JB, Lip GY, Hansen ML, Hansen PR, Tolstrup JS, Lindhardsen J, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ. 2011;342:d124.
5. Basset A, Nowak E, Castellant P, Gut-Gobert C, Le Gal G, L'her E. Development of a clinical prediction score for congestive heart failure diagnosis in the emergency care setting: the Brest score. Am J Emerg Med 2016;34:2277-83.
6. Pop-Busui R, Braffett BH, Zinman B, Martin C, White NH, Herman WH, et al, DCCT/EDIC Research Group. Cardiovascular autonomicneuropathy and cardiovascular outcomes in the diabetes control and complications trial/epidemiology of diabetes interventions and complications (DCCT/EDIC) study. Diabetes Care. 2017;40:94-100.
7. Margolis JR, Kannel WB, Feinleib M, Dawber TR, McNamara PM. Clinical features of unrecognized myocardial infarction—silent and symptomatic: eighteen year follow-up: the Framingham study. Am J Cardiol. 1973;32:1-7.
8. Stern S. Angina pectoris without chest pain: clinical implications of silent ischemia. Circulation. 2002; 106: 1906–1908
9. Phibbs B. Angina pectoris without chest pain. Circulation. 2003;108:e37-.
10. Gandaglia G, Salonia A, Passoni N, Montorsi P, Briganti A, Montorsi F. Erectile dysfunction as a cardiovascular risk factor in patients with diabetes. Endocrine. 2013 ;43:285-92.
11. Papa G, Degano C, Iurato MP, Licciardello C, Maiorana R,Finocchiaro C. Macrovascular complication phenotypes in type 2 diabetic patients. Cardiovasc Diabetol.. 2013;12 :20.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: