Before exposing patients with Type 2 diabetes to more vigorous exercise programs, the ADA and U.S. Preventive Services Task Force recommend exercise testing for silent myocardial ischemia (SMI) if 10-year cardiovascular risk exceeds 10% [
169,
245]. Cardiac dysfunction [
246] and SMI are estimated to be present between 6 and 22% [
247] of the Type 2 diabetes patients, with cardiac autonomic dysfunction, disease duration and male gender being the best predictors for SMI [
247]. Moreover, poor physical fitness [
248], scintigraphy abnormalities [
249], diabetic retinopathy [
249] and an advancing age >60 years [
250] in combination with the traditional cardiac risk factors also represent good predictors for the likelihood of a cardiac event. The UKPDS Risk Engine v2.0 (available free of charge at
www.dtu.ox.ac.uk) may be of help to calculate an individual patient’s risk for coronary heart disease [
251]. Although arbitrary, the UKPDS Risk Engine indicates that ECG stress testing in Type 2 diabetes is useful in most patients with >2 cardiovascular risk factors, in middle-aged patients with a diabetes duration >5 years, as well in elderly patients >70 years. Although a stress ECG is not the most sensitive diagnostic tool to detect SMI [
252] and predict coronary events [
253], other research indicates that it is still the most cost-effective tool when trying to minimize the risk of a coronary event [
254]. In case SMI is expected, more sensitive diagnostic tests such as myocardial perfusion scintigraphy [
255], electron beam computerized tomography [
256] and/or coronary angiography [
257] should be considered before more vigorous exercise is prescribed. Even in the absence of SMI, a stress test will detect chronotropic incompetence [
258] as well as exercise-related hypertension and provide more objective information on the individual fitness level [
205]. Ideally, this information should be used to further tailor an exercise program for the individual patient with Type 2 diabetes [
259].