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

Diabetes & CV Risk:

Routine practice versus guidelines

Eberhard Standl, MDProfessor of MedicineMunich Diabetes Research Group/Diabetes Research Institute.MDMunich, Germany

Cardio Diabetes Master ClassEuropean chapterMunich, GermanyMay 6-8, 2011

Slide lecture prepared and held by:

Presentation topic

Coronary artery disease (CAD) and diabetes (DM)

Main diagnosis DM± CAD

Main diagnosis CAD± DM

CAD unknownECG, Echocardiography,

Exercise test

DM knownScreening nephropathy If poor glucose control

(HbA1c >6.5%)Diabetology consultation

DM unknownOGTT

Blood lipids & glucoseHbA1c

If MI or ACSaim for

normoglycemia

CAD knownECG, Echocardiography,

Exercise testPositive finding

Cardiology consultation

NormalFollow up

AbnormalCardiology consultation

Ischemia treatmentNoninvasive or invasive

Newly detectedDM or IGT

± metabolic syndromeDiabetology consultation

NormalFollow up

New ESC/EASD Guidelines

Investigational algorithm

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), 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

110 from 25 countries

n= 4 961

2- 6 weeks per centreFebruary 2003 to January 2004

Euro Heart Survey Diabetes and the HeartParticipating centres

Type of centre:

47% hospital cardiology wards

45% hospital based outpatient clinics

8% outpatient clinics

Prescribed glucose

lowering drugs

77 (17%) 1% 16%

<1%83%

InsulinOral drugsCombinationsNo prescription

Newly detected diabetesn = 452

Not prescribedglucose

lowering drugs

375 (83%)

(Anselmino et al Eur Heart J 2008;29:177)

Glycemic controlExperiences from the Euro Heart SurveyGlucose lowering drugs at follow up in patients with newly detected diabetes

Euro Heart Survey Diabetes and the HeartNewly detected diabetes: Combined cardiovascular events with or without prescribed pharmacological glucose-lowering treatment

Anselmino, Malmberg, Standl, Rydén, EuroHeartJ, (2008) 29:177-184

.

NGT IFG IGT DM

Acuteadmission

n=923

389

(42%)

39

(4%)

294

(32%)

201

(22%)

Electiveconsultation

n=997

486

(49%)

50

(5%)

320

(32%)

141

(14%)

OGTT (0 min) <6.1 6.1 and <7.0 <7.0 7.0

OGTT (2 h) <7.8 <7.8 7.8 and <11.1 or 11.1

Patients with coronary artery disease (CAD) and no diabetes (OGTT cohort n=1920)

Euro Heart Survey Diabetes and theHeart OGTT outcome

Bartnik M et al. Eur Heart J 2004;25:1880–1890.

Euro Heart Survey Diabetes and the HeartFasting and post-load glycaemia in patients withCAD and without previously diagnosed diabetes

0

100

200

300

400

500

600

700

Fasting glycaemia (mmol/l) Post-load glycaemia (mmol/l)

<5.65.6-6.1

6.1-7.0≥7.0 ≥11.1

7.8-11.1

<7.8

(n=1867)

Num

ber o

f pat

ient

s

Dm

IGT

NGT

Bartnik M et al. Heart 2007;93:72–77.

CAD: coronary artery disease; OGTT: oral glucose tolerance test; FPG: fasting plasma glucose; IFG: impaired fasting glucose; IGT: impaired glucose tolerance1. Bartnik M, et al. Eur Heart J 2004;25:1880–90. 2. Hu DY, et al. Eur Heart J 2006;27:2573–9.

China Heart Survey2 (n=3,513)

~3/4 of patients have

hyperglycaemia

Euro Heart Survey1 (n=4,961)

2/3 of patients have

hyperglycaemia

Previously known diabetesNormal glucose tolerance

Prediabetes (IGT)

Newly diagnosed diabetes

33%23%

24%

20%21%

Hyperglycaemia is common and often undiagnosed in patients with CAD in Europeand Asia

25%

31%

12%3%

29%

Prediabetes (IFG)

Undiagnosed diabetes in the U.S. population aged ≥ 20 years by diagnostic criteria

0.2%

1.0%1.2%

0.1%

0.3%

2.5%FPG 2.5%

A1c 1.6%

2-h glucose 4.9%

Cowie CC et al. Diabetes Care 2010

International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes

• 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 200932: 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 %

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

Multifactorial Intervention in type 2 DiabetesEuro Heart Survey Diabetes and the Heart

(Anselmino et al Europ J Cardiovasc Prev Rehab 2008;15:216)

0 100 200 300 4000,91

0,92

0,93

0,94

0,95

0,96

0,97

0,98

0,99

1,00

No DM EBM +

No DM EBM -

DM EBM +

DM EBM -

Time of follow up (days)

Cu

mu

lativ

e s

urv

iva

lImpact of Evidence Based Medicine (EBM) on 1-year mortality

Multifactorial Intervention in type 2 DiabetesEuro Heart Survey Diabetes and the Heart

(Anselmino et al Europ J Cardiovasc Prev Rehab 2008;15:216)

Treatment type Diabetes NNT to avoid one event Fatal Cardiovascular

Evidence Based No 1826 141Medicine Yes 24 32

Revascularisation No 105 41Yes 34 14

Evidence Based Medicine

Revascularization

Number Needed to Treat with EBM and Revascularisation