Master class in preventive cardiology Focus on diabetes and cardiovascular disease Geneva April

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Master class in preventive cardiology Focus on diabetes and cardiovascular disease Geneva April 14 2011 Introduction Course

1 Master class in preventive cardiology Focus on diabetes and cardiovascular disease Geneva April Introduction Course objectives A review of available guidelines Lars Rydén Cardiology Unit Department of Medicine Karolinska Institutet Stockholm, Sweden

2 Presenter disclosure information Research grants from, Sweden (substantial) AFA Insurance, Sweden The Swedish Heart-Lung foundation Karolinska Institute funds Sanofi-Aventis Astrazeneca Lecture fees (modest) From various organisations among them Board of Health and Welfare Sweden The Swedish Medical Product Agency The Stockholm County Council European Society Cardiology Bayer, Astrazeneca, Sanofiaventis, MSD Consulting fees Astrazeneca, Roche, Sanofi-aventis

3 Course Objectives to present a practical approach to the management of patients with glucose perturbations and CV disease based available guidelines to address physicians and nurses who frequently handle problems related to the patient population in focus. specific teaching aims are to inform on epidemiology of DM and CV disease review tools for classification and screening dicuss possibilities for glycemic control inform on treatment to reduce CV risk present state of the art in managing CV-disease in DM patients address some special conditions such as ACS, renal disease and coronary interventions use interactive case presentations to exemplify the contents

4 Guidelines and clinical practice General aspects on purpose and needs

5 Prevalence of DM and IGT in Europe Adults Diabetes IGT % 48 mill 10 % 63 mill % 56 mill 11 % 71 mill

6 Diabetes and cardiovascular risk Follow up of newly detected type 2 diabetes Total mortality Cardiovascular mortality % Males Females OR 5.0 OR 5.2 OR 6.2 OR 11.4 C D C D % Males Females C D C D 5y 10y 15y (Niskanen et al Diabetes Care 1998;21:1861)

Is present management satisfactory Elective consultation 2 854 (58%) Diabetes 860

7 Is present management satisfactory Elective consultation (58%) Diabetes 860 (30%) No diabetes (70%) (Anselmino et al Europ J Cardiovasc Prev Rehab 2007;14:28)

8 Patient management in clinical practice Patient Euro Heart management Survey Diabetes in Clinical and the Heart Practice Euro Heart Survey Diabetes and the Heart Variable Target Outside Target Outside n = pat no % 2007 % Blood lipids (mmol/l) n=589 Cholesterol < n=532 LDL < n=559 HDL > n=585triglycerides < Blood pressure (mm Hg) n=746 <140/90 27 FP-glucose (mmol/l) n=573 < HbA1c (%) n=397 < (Anselmino et al Europ J Cardiovasc Prev Rehab 2008;15:216)

9 Euro Heart Survey Diabetes and the Heart Variable Target Outside Target Outside n = pat no % 2007 % Blood lipids (mmol/l) n=589 Cholesterol < < n=532 LDL < n=559 HDL > > n=585triglycerides < Blood pressure (mm Hg) n=746 <140/90 27 <130/80 56 FP-glucose (mmol/l) n=573 < < HbA1c (%) Patient management in clinical practice Patient Euro Heart management Survey Diabetes in Clinical and the Heart Practice A considerable improvement potential at least in Europe n=397 < < (Anselmino and Rydén. Data on file)

10 Guidelines and clinical practice What is the consequence?

11 Mortality (%) The Swedish CCU registry Time trends in 1-year mortality in patients with and without diabetes Patients <80 years Diabetes Diabetes Yes Yes No No (SWEDEHEART 2010)

12 Guidelines and clinical practice What can be done?

13 Guidelines Bring knowledge, experience and practice together Research Guidelines Surveys Education

14 ESC/EASD 2007 Europ Heart J 2007; 28: Can be downloaded from or

15 ESC/EASD 2007

16 Can be downloaded from IDF 2007

17 Circulation. 2008;117: AHA Diabetes Committee 2008

18 Diabetologia 2009; 52: ADA/EASD 2009

19 ADA 2010 Diabetes Care Volume 33: Suppl 1, January 2010

20 Diabetic Medicine 2008; 25: Critical views on guidelines

21 Critical views on guidelines Diabetes Research & Clin Practice 2009; 86: S 22-25

22 Some comments Originally most glycemic management and targets Guidelines relatively new in this field lack of trials Presently more directed towards comprehensive management Look for composition of authors/task forces solid evidence analysis transparent evidence grading New guidelines will appear and those existing will be updated

23 Guidelines and clinical practice Who should be addressed?

24 Guidelines for diabetes and prediabetes Two entrances Coronary artery disease (CAD) and diabetes (DM) Main diagnosis DM ± CAD Main diagnosis CAD ± DM 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 Abnormal Cardiology consultation Ischemia treatment Noninvasive or invasive Normal Follow up Newly detected DM or IGT ± metabolic syndrome Diabetology consultation

25 Guideline recommendations Recommendation Class Level Early stages of hyperglycemia and asymptomatic I B type 2 DM best diagnosed by an OGTT that gives fasting and 2-hour post-load glucose values

26 Guideline recommendations

27 The ten most 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

28 The ten most 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), 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

29 A clear need for the guidelines Diabetes and coronary artery disease - more common than imagined The negative impact of dysglycemia apparent before onset of diabetes The prognosis remains unfavorable Present management alarmingly unsatisfactory The patients deserve increased attention Therapeutic success depend on collaboration across speciality borders

30 Available guidelines for diabetes and cardiovascular disease Reflections on the needs of educating cardiologists, diabetologists and general practitioners Thanks for the attention

Master Class in Preventive Cardiology Focus on Diabetes and Cardiovascular Disease Geneva April

Master Class in Preventive Cardiology Focus on Diabetes and Cardiovascular Disease Geneva April 14 2011 Coronary interventions in patients with diabetes Lars Rydén Karolinska Institutet Stockholm, Sweden