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The concept of Diabetes & CV risk: A lifetime risk challenge

Cardio Diabetes Master Class European chapter Munich, Germany May 6-8, 2011. The concept of Diabetes & CV risk: A lifetime risk challenge. Diabetes & CV Risk: Routine practice versus guidelines. Presentation topic. Slide lecture prepared and held by:. Eberhard Standl, MD

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The concept of Diabetes & CV risk: A lifetime risk challenge

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  1. Cardio Diabetes MasterClass Europeanchapter Munich, Germany May 6-8, 2011 The concept of Diabetes & CV risk:A lifetime risk challenge Diabetes & CV Risk: Routine practice versus guidelines Presentation topic Slide lecture prepared and held by: Eberhard Standl, MD Professor of Medicine Munich Diabetes Research Group/ Diabetes Research Institute.MD Munich, Germany

  2. New ESC/EASD Guidelines Investigational algorithm Coronary artery disease (CAD) and diabetes (DM) Main diagnosis CAD ± DM Main diagnosis DM ± CAD CAD unknown ECG, Echocardiography, Exercise test CAD known ECG, Echocardiography, Exercise test Positive finding Cardiology consultation DM unknown OGTT Blood lipids & glucose HbA1c If MI or ACS aim for normoglycemia DM known Screening nephropathy If poor glucose control (HbA1c >6.5%) Diabetology consultation Normal Follow up Newly detected DM or IGT ± metabolic syndrome Diabetology consultation Normal Follow up Abnormal Cardiology consultation Ischemia treatment Noninvasive or invasive

  3. 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 (1)

  4. 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), eGFR 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 Ten important recommendations (2)

  5. 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 (Bartnik et al Eur Heart J 2004; 25:1880-90)

  6. Insulin Oral drugs Combinations No prescription 1% 16% <1% 83% 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 Prescribed glucose lowering drugs 77 (17%) Not prescribed glucose lowering drugs 375 (83%) (Anselmino et al Eur Heart J 2008;29:177)

  7. Euro Heart Survey Diabetes andthe HeartNewly detected diabetes: Combined cardiovascular events with or without prescribed pharmacological glucose-lowering treatment Anselmino, Malmberg, Standl, Rydén, EuroHeartJ, (2008) 29:177-184 .

  8. 389 39 294 201 Acute admission n=923 (42%) (4%) (32%) (22%) 486 50 320 141 Elective consultation n=997 (49%) (5%) (32%) (14%) Euro Heart Survey Diabetes and theHeart OGTT outcome Patients with coronary artery disease (CAD) and no diabetes (OGTT cohort n=1920) NGT IFG IGT DM <6.1 6.1 and <7.0 <7.0 7.0 OGTT (0 min) <7.8  7.8 and <11.1 or 11.1 OGTT (2 h) <7.8 Bartnik M et al. Eur Heart J 2004;25:1880–1890.

  9. Euro Heart Survey Diabetes andthe HeartFastingand post-loadglycaemia in patientswithCAD andwithoutpreviouslydiagnoseddiabetes (n=1867) Number of patients NGT IGT <5.6 <7.8 5.6-6.1 Dm 7.8-11.1 6.1-7.0 Fasting glycaemia (mmol/l) ≥7.0 ≥11.1 Post-load glycaemia (mmol/l) Bartnik M et al. Heart 2007;93:72–77.

  10. Hyperglycaemia is common and often undiagnosed in patients with CAD in Europeand Asia Euro Heart Survey1 (n=4,961) China Heart Survey2 (n=3,513) 23% 29% 31% 33% 2/3 of patients have hyperglycaemia 3% ~3/4 of patients have hyperglycaemia 24% 12% 21% 25% 20% Normal glucose tolerance Newly diagnosed diabetes Prediabetes (IFG) Previously known diabetes Prediabetes (IGT) 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.

  11. Undiagnosed diabetes in the U.S. population aged ≥ 20 years by diagnostic criteria FPG 2.5% 2.5% 0.2% 0.1% 1.2% 0.3% 1.0% A1c 1.6% 2-h glucose 4.9% Cowie CC et al. Diabetes Care 2010

  12. International Expert Committeereport on theroleofthe A1C assay in thediagnosisofdiabetes • A1C ≥ 5.7% to < 6,5% high risk for Diabetes • A1C ≥ 6,5% undiagnosed diabetes • ADA : or FPG > 7.0 mmol/l and/or post load ≥ 11.1 mmol/l Diabetes Care 2009 32: 1327 -1334 WHO position statement 2011: HbA1c > 6.5 diagnostic for DM, levels below do not exclude diagnosis using glucose tests, no formal recommendation to interprete levels < 6.5 %

  13. 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 10y 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

  14. 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 0,99 No DM EBM + 0,98 No DM EBM - 0,97 DM EBM + 0,96 Cumulative survival 0,95 0,94 0,93 DM EBM - 0,92 0,91 0 100 200 300 400 Time of follow up (days) (Anselmino et al Europ J Cardiovasc Prev Rehab 2008;15:216)

  15. Evidence Based Medicine Revascularization Evidence Based No 1826 141 Medicine Yes 24 32 Revascularisation No 105 41 Yes 34 14 Multifactorial Intervention in type 2 Diabetes Euro Heart Survey Diabetes and the Heart NumberNeeded to Treat with EBM and Revascularisation Treatmenttype Diabetes NNT to avoidone event Fatal Cardiovascular (Anselmino et al Europ J Cardiovasc Prev Rehab 2008;15:216)

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