Cardio Diabetes Master Class European chapter Munich Germany
Cardio Diabetes Master Class European chapter Munich, Germany May 6 -8, 2011 Presentation topic Diabetes & CV Risk: Routine practice versus guidelines Slide lecture prepared and held by: Eberhard Standl, MD Professor of Medicine Munich Diabetes Research Group/ Diabetes Research Institute. MD Munich, Germany
New ESC/EASD Guidelines Investigational algorithm Coronary artery disease (CAD) and diabetes (DM) Main diagnosis CAD ± DM Main diagnosis DM ± CAD unknown CAD known DM unknown DM known ECG, Echocardiography, Exercise test Positive finding Cardiology consultation OGTT Blood lipids & glucose Hb. A 1 c If MI or ACS aim for normoglycemia Screening nephropathy If poor glucose control (Hb. A 1 c >6. 5%) Diabetology consultation Normal Abnormal Follow up Cardiology consultation Ischemia treatment Noninvasive or invasive Normal Newly detected Follow up DM or IGT ± metabolic syndrome Diabetology consultation
Ten important recommendations (1) § To reach (all) treatment targets including those for glycaemic control § To screen for DM and IGT by means of an OGTT in all patients with coronary artery disease and in other high risk individuals § To let life style counselling be the cornerstone in preventing DM and CVD § To offer patients with DM and ACS standard guideline based treatment, early angiography and mechanical revascularisation § To apply strict, when needed insulin based, glucose control in acutely ill DM patients
Ten important recommendations (2) § To favour CABG over PCI when revascularising DM patients § To use drug-eluting stents in PCI with stent implantation § To include investigations for cardiac autonomic dysfunction, heart failure, arrhythmias, hypotension, PVD (Doppler-Index), e. GFR and (micro) - albuminuria § To use a multifactorial (tight glucose, BP and lipid-control and antiplatelet therapy) approach § To establish a collaboration between cardiologists and diabetologists
Euro Heart Survey Diabetes and the Heart Participating centres 110 from 25 countries n= 4 961 Type of centre: 47% hospital cardiology wards 45% hospital based outpatient clinics 8% outpatient clinics 2 - 6 weeks per centre February 2003 to January 2004
Glycemic control Experiences from the Euro Heart Survey Glucose lowering drugs at follow up in patients with newly detected diabetes Newly detected diabetes n = 452 1% 16% Prescribed glucose lowering drugs 77 (17%) <1% 83% Insulin Oral drugs Combinations No prescription (Anselmino et al Eur Heart J 2008; 29: 177) Not prescribed glucose lowering drugs 375 (83%)
Euro Heart Survey Diabetes and the Heart Newly detected diabetes: Combined cardiovascular events with or without prescribed pharmacological glucose-lowering treatment Anselmino, Malmberg, Standl, Rydén, Euro. Heart. J, (2008) 29: 177 -184.
Euro Heart Survey Diabetes and the Heart OGTT outcome Patients with coronary artery disease (CAD) and no diabetes (OGTT cohort n=1920) NGT IFG IGT DM OGTT (0 min) OGTT (2 h) <6. 1 <7. 8 6. 1 and <7. 0 7. 8 and <11. 1 7. 0 or 11. 1 Acute admission n=923 389 39 294 201 (42%) (4%) (32%) (22%) 486 50 320 141 (49%) (5%) (32%) (14%) Elective consultation n=997 <7. 8 Bartnik M et al. Eur Heart J 2004; 25: 1880– 1890.
Euro Heart Survey Diabetes and the Heart Fasting and post-load glycaemia in patients with CAD and without previously diagnosed diabetes Number of patients (n=1867) NGT IGT <5. 6 <7. 8 5. 6 -6. 1 -7. 0 Fasting glycaemia (mmol/l) Dm ≥ 7. 0 7. 8 -11. 1 ≥ 11. 1 Post-load glycaemia (mmo Bartnik M et al. Heart 2007; 93: 72– 77.
Hyperglycaemia is common and often undiagnosed in patients with CAD in Europe and Asia Euro Heart Survey 1 (n=4, 961) 31% 12% China Heart Survey 2 (n=3, 513) 29% 33% 3% 2/3 of 21% patients have 25% hyperglycaemia Normal glucose tolerance Prediabetes (IFG) Prediabetes (IGT) 23% 24% 20% ~3/4 of patients have hyperglycaemia Newly diagnosed diabetes Previously known diabetes CAD: coronary artery disease; OGTT: oral glucose tolerance test; FPG: fasting plasma glucose; IFG: impaired fasting glucose; IGT: impaired glucose tolerance 1. Bartnik M, et al. Eur Heart J 2004; 25: 1880– 90. 2. Hu DY, et al. Eur Heart J 2006; 27: 2573– 9.
Undiagnosed diabetes in the U. S. population aged ≥ 20 years by diagnostic criteria FPG 2. 5% 0. 2% 0. 1% 1. 2% 0. 3% 1. 0% A 1 c 1. 6% 2 -h glucose 4. 9% Cowie CC et al. Diabetes Care 2010
International Expert Committee report on the role of the A 1 C assay in the diagnosis of diabetes • A 1 C ≥ 5. 7% to < 6, 5% high risk for Diabetes • A 1 C ≥ 6, 5% undiagnosed diabetes • ADA : or FPG > 7. 0 mmol/l and/or post load ≥ 11. 1 mmol/l WHO position statement 2011: Hb. A 1 c > 6. 5 diagnostic for DM, levels below do not exclude diagnosis using glucose tests, no formal Diabetes recommendation to interprete levels < 6. 5 % Care 2009 32: 1327 -1334
Type 2 Diabetes: some evidence based recommendations in primary CV prevention 2011 • Evidence for CHD risk equivalence: controversial, but total risk has decreased, i. e. to 10 -15% over 10 y in the best case scenario vs some 25% with silent myocardial ischemia • Should every diabetic be on low dose aspirin? – probably not (bleeding hazards), however rather limited data base • Should every diabetic be on a statin with a LDL target of 70 mg/dl? – probably yes, but more studies warranted • Should every diabetic be on anti-RAS therapy? Probably yes, but avoid hypotension, especially with preexisting CVD • Silent myocardial ischemia in totally asymptomatic patients with diabetes – is frequent, some 30 %, and with high risk (see above). Appropriate multifactorial therapy plus good medical monitoring for signs and symptoms of CHD effective and economic approach
Multifactorial Intervention in type 2 Diabetes Euro Heart Survey Diabetes and the Heart Impact of Evidence Based Medicine (EBM) on 1 -year mortality 1, 00 Cumulative survival 0, 99 No DM EBM + 0, 98 0, 97 0, 96 0, 95 0, 94 0, 93 DM EBM - 0, 92 0, 91 0 100 200 300 Time of follow up (days) (Anselmino et al Europ J Cardiovasc Prev Rehab 2008; 15: 216) 400
Multifactorial Intervention in type 2 Diabetes Euro Heart Survey Diabetes and the Heart Number Needed to Treat with EBM and Revascularisation Evidence Based Medicine Revascularization Treatment type Diabetes NNT to avoid one event Fatal Cardiovascular Evidence Based Medicine No Yes 1826 24 141 32 Revascularisation No Yes 105 34 41 14 (Anselmino et al Europ J Cardiovasc Prev Rehab 2008; 15: 216)
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