What do the Guidelines say? Clinical Case: A diabetic patient undergoing revascularization

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1 What do the Guidelines say? Clinical Case: diabetic patient undergoing revascularization Professor Steen D. Kristensen, FESC Department of Cardiology arhus University Hospital Denmark UNVERSTY OF RHUS 1

2 2013 ESC Guidelines on Diabetes, Pre-diabetes and Cardiovascular Diseases Developed in Collaboration with ESD Co-chairs Lars Rydén (ESC; Sweden) Peter J. Grant (ESD; United Kingdom) Task Force Members n =20 n =13 European Heart Journal doi: /eurheartj/eht108

3 European Heart Journal doi: /eurheartj/eht296 ESC GUDELNES 2013 ESC guidelines on the management of stable coronary artery disease The Task Force on the management of stable coronary artery disease of the European Society of Cardiology uthors/task Force Members: Gilles Montalescot* (Chairperson) (France), Udo Sechtem* (Chairperson) (Germany). Stephan chenbach (Germany), Felicita ndreotti (taly), Chris rden (UK), ndrzej Budaj (Poland), Raffaele Bugiardini (taly), Filippo Crea (taly), Thomas Cuisset (France), Carlo Di Mario (UK), J. Rafael Ferreira (Portugal), Bernard J. Gersh (US), nselm K. Gitt (Germany), Jean-Sebastien Hulot (France), Nikolaus Marx (Germany), Lionel H. Opie (South frica), Matthias Pfisterer (Switzerland), Eva Prescott (Denmark), Frank Ruschitzka (Switzerland), Manel Sabaté (Spain), Roxy Senior (UK), David Paul Taggart (UK), Ernst E. van derwall (Netherlands), Christiaan J.M. Vrints (Belgium). ESC Committee for Practice Guidelines (CPG): Jose Luis Zamorano (Chairperson) (Spain), Stephan chenbach (Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), Héctor Bueno (Spain), Veronica Dean (France), Christi Deaton (UK), Çetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (taly), David Hasdai (srael), rno W. Hoes (Netherlands), Paulus Kirchhof (Germany UK), Juhani Knuuti (Finland), Philippe Kolh, (Belgium), Patrizio Lancellotti (Belgium), les Linhart (Czech Republic), Petros Nihoyannopoulos (UK), Massimo F. Piepoli (taly), Piotr Ponikowski (Poland), Per nton Sirnes (Norway), Juan Luis Tamargo (Spain), Michal Tendera (Poland), dam Torbicki (Poland),William Wijns (Belgium), Stephan Windecker (Switzerland). Document Reviewers: Juhani Knuuti (CPG Review Co-ordinator) (Finland), Marco Valgimigli (Review Co-ordinator) (taly), Héctor Bueno (Spain), Marc J. Claeys (Belgium), Norbert Donner-Banzhoff (Germany), Cetin Erol (Turkey), Herbert Frank (ustria), Christian Funck-Brentano (France), Oliver Gaemperli (Switzerland), José R. Gonzalez-Juanatey (Spain), Michalis Hamilos (Greece), David Hasdai (srael), Steen Husted (Denmark), Stefan K. James (Sweden), Kari Kervinen (Finland), Philippe Kolh (Belgium), Steen Dalby Kristensen (Denmark), Patrizio Lancellotti (Belgium), ldo Pietro Maggioni (taly), Massimo F. Piepoli (taly), xel R. Pries (Germany), Francesco Romeo (taly), Lars Rydén (Sweden), Maarten L. Simoons (Netherlands), Per nton Sirnes (Norway), Ph. Gabriel Steg (France), dam Timmis (UK), William Wijns (Belgium), Stephan Windecker (Switzerland), ylin Yildirir (Turkey), Jose Luis Zamorano (Spain). European Heart Journal doi: /eurheartj/eht296

4 European Heart Journal doi: /eurheartj/ehu278

5 65 year old lady with DM (and hypertension) Simvastatin 40 mg spirin 75 mg Ramipril 5 mg Metformin x mg UNVERSTY OF RHUS 5

Recommendations for Blood Pressure Control in Diabetes Recommendations Class Level Blood pressure control is recommended in patients with DM and hypertension to lower the risk of cardiovascular

6 Recommendations for Blood Pressure Control in Diabetes Recommendations Class Level Blood pressure control is recommended in patients with DM and hypertension to lower the risk of cardiovascular events. t is recommended that a patient with hypertension and DM is treated in an individualized manner, targeting a blood pressure of <140/85 mmhg. t is recommended that a combination of blood pressure lowering agents is used to achieve blood pressure control. RS blocker (CE- or RB) is recommended in the treatment of hypertension in DM, particularly in the presence of proteinuria or microalbuminuria Simultaneous administration of two RS blockers should be avoided in DM. B

7 65 year old lady with DM and hypertension Simvastatin 40 mg spirin 75 mg Ramipril 5 mg Metformin UNVERSTY OF RHUS 7

8 Recommendations for Lipid Management in Diabetes Recommendations Class Level Statin therapy is recommended in patients with T1DM and T2DM at very high risk (i.e. if combined with documented CVD, severe CKD or with one or more CV risk factors and/or target organ damage) with an LDL-C target of <1.8 mmol/l (<70 mg/dl) or at least a 50% LDL-C reduction if this target goal cannot be reached. Statin therapy is recommended in patients with T2DM at high risk (without any other CV risk factor and free of target organ damage) with an LDL-C target of <2.5 mmol/l (<100 mg/dl). Statins may be considered in T1DM patients at high risk for cardiovascular events irrespective of the basal LDL-C concentration. t may be considered to have a secondary goal of non HDL-C <2.6 mmol/l (<100 mg/dl) in patients with DM at very high risk and of <3.3 mmol/l (<130 mg/dl) in patients at high risk. ntensification of statin therapy should be considered before the introduction of combination therapy with the addition of ezetimibe. The use of drugs that increase HDL-C to prevent CVD in T2DM is not recommended. b b a C C C

9 65 year old lady with DM and hypertension Simvastatin 40 mg spirin 75 mg Ramipril 5 mg Metformin UNVERSTY OF RHUS 9

10 spirin in Diabetes Secondary prevention Low-dose aspirin uniformly recommended for acute treatment of ischaemic syndromes and secondary prevention Primary prevention Evidence for efficacy and safety in this setting is lacking or at best inconclusive Risk benefit ratio Estimated to vary considerably depending on age and history of peptic ulcer disease

11 Recommendation for ntiplatelet Therapy n Diabetes Recommendations Class Level ntiplatelet therapy with aspirin in DM-patients at low CVD risk is not recommended. ntiplatelet therapy for primary prevention may be considered in high risk patients with DM on an individual basis. spirin at a dose of mg/day is recommended as secondary prevention in DM. P2Y 12 receptor blocker is recommended in patients with DM and CS for 1 year and in those subjected to PC (duration depending on stent type). n patients with PC for CS preferably prasugrel or ticagrelor should be given. Clopidogrel is recommended as an alternative antiplatelet therapy in case of aspirin intolerance. b C B

12 Recommendation for ntiplatelet Therapy n Diabetes Recommendations Class Level ntiplatelet therapy with aspirin in DM-patients at low CVD risk is not recommended. ntiplatelet therapy for primary prevention may be considered in high risk patients with DM on an individual basis. spirin at a dose of mg/day is recommended as secondary prevention in DM. P2Y 12 receptor blocker is recommended in patients with DM and CS for 1 year and in those subjected to PC (duration depending on stent type). n patients with PC for CS preferably prasugrel or ticagrelor should be given. Clopidogrel is recommended as an alternative antiplatelet therapy in case of aspirin intolerance. b C B

13 65 year old lady with DM maging Echo? schaemia test? UNVERSTY OF RHUS 13

14 Echocardiography Recommendations Class Level Ref. resting transthoracic echocardiogram is recommended in all patients for: a) exclusion of alternative causes of angina; b) identification of regional wall motion abnormalities suggestive of CD; c) measurement of LVEF for risk stratification purpose; d) evaluation of diastolic function. B Ultrasound of the carotid arteries should be considered to be performed by adaequately trained clinicians to detect increased MT and/or plaque in patients with suspected SCD without known atherosclerotic disease. a C CD = coronary artery disease; MT = ntima-media thickness; LVEF = left ventricular ejection fraction; SCD = stable coronary artery disease. European Heart Journal doi: /eurheartj/eht296

Characteristics of tests commonly used to diagnose the presence of CD www.escardio.

15 Characteristics of tests commonly used to diagnose the presence of CD Diagnosis of CD Sensitivity (%) Specificity (%) Exercise ECG a, 91, 94, Exercise stress echocardiography Exercise stress SPECT Dobutamine stress echocardiography Dobutamine stress MR b, Vasodilator stress echocardiography Vasodilator stress SPECT 96, Vasodilator stress MR b, 98, Coronary CT c, Vasodilator stress PET 97, 99, CD = coronary artery disease; CT = computed tomography angiography; ECG = electrocardiogram; MR = magnetic resonance imaging; PET = positron emission tomography; SPECT = single photon emission computed tomography. a Results without/with minimal referral bias; b Results obtained in populations with medium-to-high prevalence of disease without compensation for referral bias; c Results obtained in populations with low-to-medium prevalence of disease. European Heart Journal doi: /eurheartj/eht296

16 Performing an exercise ECG for initial diagnostic assessment of angina or evaluation of symptoms Recommendations Class Level Ref. Exercise ECG is recommended as the initial test for establishing a diagnosis of SCD in patients with symptoms of angina and intermediate PTP of CD, free of anti-ischaemic drugs, unless they cannot exercise or display ECG changes which make the ECG non evaluable. Stress imaging is recommended as the initial test option if local expertise and availability permit. Exercise ECG should be considered in patients on treatment to evaluate control of symptoms and ischaemia. Exercise ECG in patients with 0,1 mv ST-depression on resting ECG or taking digitalis is not recommended for diagnostic purposes. B 115, 116 B a C CD = coronary artery disease; ECG = electrocardiogram; PTP = pre-test probability; SCD = stable coronary artery disease. C European Heart Journal doi: /eurheartj/eht296

17 Managing Metformin During Coronary ngiography and PC Stopping metformin before coronary angiography or PC is not justified Renal function should be carefully monitored f compromised, withhold metformin for 48h or until improvement

18 65 year old lady with DM Revascularization? UNVERSTY OF RHUS 18

al. N Engl J Med 2012; 367:2375-84 Death, M, or Stroke

19 Strategies for Multivessel Revascularization in Patients with Diabetes the FREEDOM Trial Farkouh ME et al. N Engl J Med 2012; 367: Death, M, or Stroke Through 5 Years Median SYNTX-Score = % 13.0% 11.9% 18.7%

20 Meta-analysis: DES vs CBG in Diabetic Patients Hakeem et al. J m Heart ssoc EP MCE: Death, M, or 4 Years Sensitivity nalysis ccording to SYNTX score

21 Death, myocardial infarction, or stroke (%) Death from any cause (%) CBG vs. PC in Diabetes The FREEDOM trial Primary Outcome Death p=0.005 by log rank test 5-year event rate 26.6 vs.18.7% p=0.049 by log rank test 5-year event rate 16.3 vs.10.9% PC PC 10 0 CBG CBG Years since randomization Years since randomization Farkouh et al New Engl J Med 2012; 367: 2375

22 ndications for revascularisation in stable angina or silent ischaemia a With documented ischaemia or Fractional Flow Reserve (FFR) <0.80 for angiographic diameter stenosis 50-90%. European Heart Journal doi: /eurheartj/ehu278

Revascularisation in Diabetes Recommendations Class Level Optimal medical treatment should be considered as preferred treatment in patients with stable CD and DM unless there are large areas of

23 Revascularisation in Diabetes Recommendations Class Level Optimal medical treatment should be considered as preferred treatment in patients with stable CD and DM unless there are large areas of ischaemia or significant left main or proximal LD lesion. CBG is recommended in patients with DM and multivessel or complex (SYNTX Score >22) CD to improve survival free from major cardiovascular events. PC for symptom control may be considered as an alternative to CBG in patients with DM and less complex multivessel CD (SYNTX score 22) in need of revascularization. Primary PC is recommended over fibrinolysis in DM patients presenting with STEM if performed within recommended time limits. n DM patients subjected to PC, DES rather than BMS are recommended to reduce risk of target vessel revascularization. Renal function should be carefully monitored after coronary angiography/pc in all patients on metformin. f renal function deteriorates in patients on metformin undergoing coronary angiography/pc it is recommended to withhold treatment for 48 h or until renal function has returned to its initial level. a b B B B C C

24 Pocket Guidelines European Heart Journal doi: /eurheartj/eht296

25 Specific recommendations in diabetic patients European Heart Journal doi: /eurheartj/ehu278

26 Specific recommendations in diabetic patients European Heart Journal doi: /eurheartj/ehu278

27 Treatment Targets for Multifactorial Management of Diabetes Blood pressure (mmhg) n case of nephropathy <140/85 Systolic <130 Glycaemic control Hb 1c Lipid profile LDL-Cholesterol Generally <7.0 (53 mmol/mol) On an individual basis < % (48-52 mmol/mol) Very high risk patients <1.8 mmol/l (<70 mg/dl) or reduced at least 50% High risk patients <2.5 mmol/l (<100 mg/dl) Patelet stabilization Smoking Physical activity Patients with CVD and DM S mg/day Cessation obligatory; passive smoking - none Moderate to vigorous 150 min/week Weight Dietary habits Fat intake (% of dietary energy) Total Saturated Monounsaturated fatty acids Dietary fibre intake im for weight stabilization in the overweight or obese DM patients based on calorie balance, and weight reduction in subjects with GT to prevent development of T2DM <35% <10% >10% >40 g/day (or 20 g/1000 Kcal/day)

28 Recommendations for Multifactorial Treatment in Diabetes Recommendations Class Level Risk stratification should be considered as part of the evaluation of patients with DM and GT. Cardiovascular risk assessment is recommended in people with DM and GT as a basis for multifactorial management. Treatment targets, as listed in Table 3, should be considered in patients with DM and GT with CVD. a a C B B

Diagnostic Algorithms

Diagnostic Algorithms Udo Sechtem Robert-Bosch-Krankenhaus Stuttgart Germany Montalescot G et al. ESC Guideline on the Management of Stable Coronary Artery Disease Eur Heart J. 2013;34:2949-3003. European