ACCORD, ADVANCE & VADT. Now what do I do in my practice?
|
|
- Martin Morton
- 6 years ago
- Views:
Transcription
1 ACCORD, ADVANCE & VADT Now what do I do in my practice? Richard M. Bergenstal, MD International Diabetes Center Park Nicollet Health Services University of Minnesota Minneapolis, MN richard.bergenstal@parknicollet.com
2 Presenter Disclosure Information Richard M. Bergenstal, MD I have participated in clinical research, served on a scientific advisory board and/or consulted with: Eli Lilly Novo Nordisk Sanofi-Aventis MannKind I have inherited Merck stock Roche LifeScan / J&J Abbott Bayer Medtronic Intuity Valeritas Amylin Merck Pfizer ResMed Novartis I have received no personal compensation for any of these activities and all contracts are with the non-profit Park Nicollet Institute for Research & Education Current officer of the American Diabetes Association
3 In the News: February 7, 2008 The ACCORD Trial and Diabetes Care Diabetes Study Halted After Deaths Deaths Prompt Halt in Diabetes Study: Study of Intensive Treatment of Diabetes Curtailed Because of Increased Death Rates International Diabetes Center Park Nicollet
4 ACCORD: 3 Medical Strategy Questions Glycemia (open-label trial) (n=10,251) Intensive treatment (A1C<6.0%) vs Standard treatment (A1C 7.0%-7.9%) BP (open-label trial) (n=4,733) Intensive treatment (SBP <120 mmhg) vs Standard treatment (SBP <140 mmhg) Lipids (double-blind trial) (n=5,518) Fibrate to increase HDL-C and lower TG + statin to lower LDL-C vs Placebo + Statin to lower LDL-C (ACCORD Study Group, Am J Cardiol 2007;99[suppl]:21i-33i)
5 ACCORD Double 2 x 2 Factorial Design ADVANCE VADT Intensive (SBP<120) BP Standard (SBP<140) Lipid stain + fibrate vs statin + placebo Group A Group B Intensive Glycemic Treatment (A1C<6%) * Standard Glycemic Treatment (A1C 7-7.9%) * 2362* 2371* 2753* 2765* 10,251 *Primary analyses compare marginals for main effects (ACCORD Study Group, Am J Cardiol 2007;99[suppl]:21i-33i)
6 Comparison of Recent Glycemia Trials ACCORD, ADVANCE and VADT Characteristic ACCORD ADVANCE VADT N 10,251 11,140 1,791 Mean Age Duration of T2DM 10 yr 8 yr 11.5 yr History of CVD 35% 32% 40% BMI Baseline A1C 8.3% 7.5% 9.4% ACCORD Study Group. N Engl J Med. 2008;358: ADVANCE Collaborative Group. N Engl J Med 358: , Duckworth W for VADT. N Engl J Med 2009;360:129-39
7 Comparison of Recent Glycemia Trials ACCORD, ADVANCE and VADT Characteristic ACCORD ADVANCE VADT N 10,251 11,140 1,791 Mean Age Duration of T2DM 10 yr 8 yr 11.5 yr History of CVD 35% 32% 40% BMI Baseline A1C 8.3% 7.5% 9.4% A1C Achieved 6.4% vs. 7.5% 6.5% vs. 7.3% 6.9% vs. 8.4% RRR CVD Events 0.90 ( ) 0.94 ( ) 0.88 ( ) RRR Mortality 1.22 ( )* 0.93 ( ) 1.07 ( ) ACCORD Study Group. N Engl J Med. 2008;358: ADVANCE Collaborative Group. N Engl J Med 358: , Duckworth W for VADT. N Engl J Med 2009;360:129-39
8 Impact of Intensive Therapy for Diabetes: Summary of Major Clinical Trials Study Microvascular CVD Mortality UKPDS DCCT/EDIC ACCORD Pending ADVANCE VADT Initial Trial International Diabetes Center 2008 UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352: Holman RR. N Engl J Med Oct 9;359(15): DCCT Research Group. N Engl J Med 329; , 1993 Nathan DM, et al. N Engl J Med. 2005;353: Gerstein HC, et al. N Engl J Med. 2008;358: Patel A, et al. N Engl J Med. 2008;358: Duckworth W et al N Engl J Med 2009;360: Long Term Follow-up
9 Intensive Glycemic Control in Diabetes: Implications of ACCORD, ADVANCE and VADT Skyler JS. Diabetes Care. 2009;32(1):187-92
10 Intensive Glycemic Control in Diabetes: Implications of ACCORD, ADVANCE and VADT Glycemic targets Lowering A1C to < 7% significantly lowers the risk of microvascular complications in both type 1 and type 2 diabetes Controlled trials of more intensive glycemic control have not demonstrated a reduction in CVD risk Long-term follow-up suggests that A1C < 7% soon after diagnosis is associated with a reduction in CVD risk years later Until more evidence becomes available, the general A1C target of < 7% is reasonable For selected patients lower or higher A1C targets may be appropriate Skyler JS. Diabetes Care. 2009;32(1): Also published in Circulation and American College of Cardiology
11 Post ADA ACCORD, ADVANCE, VADT I told you glucose control was not important New A1C goal should be <8% - no make that <9% I am sure it was the severe hypoglycemia that killed people I am sure it was silent hypoglycemia coupled with autonomic n. I am sure it was the weight gain that killed people I am sure it was how rapidly the A1C was lowered that killed people Those with diabetes of long duration & known heart disease died Cardiologists were right its all about lipids and blood pressure Time to rewrite guidelines and treatment algorithms ---
12 1. Meta analysis 2. More detailed secondary analyses of ACCORD and VADT data
13 A Broader View of CVD and Diabetes Implications of ACCORD, ADVANCE and VADT A few observation and much reasoning lead to error. Many observations and a little reasoning to truth Alexis Carrel
14 Prevention of CVD Thru Glycemic Control CVD Events and Mortality Risk Mannucci E et al. Nutr Metab Cardiovasc Dis epub ahead of print 8 May 2009
15 Ray et al Lancet May 2009 Meta analysis of RCT s: CVD & Death in DM Non- fatal MI All CHD events
16 Ray et al Lancet May 2009 Stroke Meta analysis of RCT s: CVD & Death in DM All Cause Mortality
17 The ACCORD and ADVANCE Glycemic Control Intensive vs Standard A1C (%) A1C (%) Standard therapy Intensive therapy Time (yrs) Standard control Intensive control Follow-up (months) ACCORD Study Group. N Engl J Med. 2008;358: A1C 7.5% 6.4% A1C 7.0% 6.4%
18 INT vs STD strategy Post-Rz Differences Lower A1C Achieved median 6.4% vs 7.5% Greater use of medications: More multiple oral meds More insulin More consequences of therapy: Severe hypoglycemia Weight gain More SAEs 11% vs 2% on 4-5 oral classes 77% vs 55% on insulin 10.5% vs 3.5% w/ hypoglycemia event requiring medical assistance 28% vs 14% >10 kg gain 2.2% vs 1.6% w non-hypo SAE (NEJM 358:2545, 2008)
19 Can we predict what baseline characteristics increase risk of death? DEMOGRAPHICS MEDICAL HISTORY MEDICATIONS LAB TESTS Age Race/ethnicity Gender Lives alone Clinical network BMI Waist circumference Education Year of randomization Prior CVD event Prior HF DM duration Hx neuropathy Peripheral Neuropathy (MNSI) Retinal laser/surgery Visual acuity Smoking Depression Blood Pressure ECG (MI, QT) SU Metformin TZD Any insulin HCTZ ACE inhibitors Beta blockers CCB Fibrates Statins Aspirin Antidepressants A1C LDL HDL TG Serum Cr GFR (MDRD) Alb/Cr urine
20 Can we predict what baseline characteristics increase risk of death? DEMOGRAPHICS MEDICAL HISTORY MEDICATIONS LAB TESTS Age Race/ethnicity Gender Lives alone Clinical network BMI Waist circumference Education Year of randomization Prior CVD event Prior HF DM duration Hx neuropathy Peripheral Neuropathy (MNSI) Retinal laser/surgery Visual acuity Smoking Depression Blood Pressure ECG (MI, QT) SU Metformin TZD Any insulin HCTZ ACE inhibitors Beta blockers CCB Fibrates Statins Aspirin Antidepressants A1C LDL HDL TG Serum Cr GFR (MDRD) Alb/Cr urine
21 Risk of Death (all-cause) in INT vs. STD Subgroups w/ significant interactions Baseline Subgroup % Deaths (N) STD % Deaths (N) INT INT vs STD Hazard Ratio Interaction P-Value Hba1c < % (1022) 7.5 to % (2200) % (1887) Self-report Hx Neuropathy 4.83% (1036) 4.18% (2226) 6.14% (1857) Yes 4.11% (1410) 7.84% (1327) No 3.84% (3646) 4.10% (3708) Aspirin Use Yes 3.83% (2771) 5.73% (2808) No 4.12% (2352) 4.14% (2320) INT Better STD Better
22 Marginal Significance BMI (interaction p = 0.07) Anti-depressants (interaction p=0.08) Expected, But No Interaction with Treatment Age Prior history of CVD Diabetes Duration
23 Severe Hypoglycemia
24 Severe Hypoglycemia Rates in INT & STD Groups INT intensive STD standard Pts w hypoglycemia events (%) Participants With Hypoglycemic Events (%) Years
25 Persons more or less likely to have severe hypoglycemic event (multivariate analysis) Albumin:creatinine >300: HR 1.74 (95% CI: ) African American: HR 1.43 (95% CI: ) Women: HR 1.21 (95% CI: ) Every 1 yr increase in age: HR 1.03 (95% CI: 1.02, 1.05) BMI > 30: HR 0.65 (95% CI: )
26 Self-reported Antecedents to Hypoglycemia Events Reason % (n=875 events) Delayed/missed meal or ate fewer carbohydrates 58% (510) None 17% (148) Took incorrect dose of glucose lowering medication 9% (82) Cognitive decline 8% (70) Intercurrent illness 5% (44) Ingested alcohol 3% (26) Recent weight loss 3% (29) Started or increase of other medication 3% (28)
27 Risk of Hypoglycemia by Study Group and Average Updated A1C Incidence Per 100 Person Years Intensive INT Standard STD HR for hypoglycemia by each 1% higher updated average A1C: Intensive = 1.15 Standard = 1.76 Higher A1C assoc w/ higher hypoglycemic rates within both groups Updated Average A1C (Quintiles)
28 The ACCORD and ADVANCE Glycemic Control Intensive vs Standard A1C (%) A1C (%) Standard therapy Intensive therapy Time (yrs) Standard control Intensive control Follow-up (months) ACCORD Study Group. N Engl J Med. 2008;358: A1C 7.5% 6.4% A1C 7.0% 6.4%
29 Hypoglycemia Rate Of A1C Change From BL To 4 Months Incidence Per 100 Person Years INT STD HR for hypoglycemia by initial 4-month decrease of an additional percentage point in A1C: Intensive = 0.86 Standard = 0.72 Greater reduction in A1C assoc with lower hypoglycemia rates Baseline A1C Minus Month 4 A1C (Quintiles)
30 No severe hypoglycemia At least one severe hypoglycemia event HR (Hypo vs no Hypo) (95% CI) Mortality by Study Group and Hypoglycemia Occurrence STD (n=175 w/ events) 1.0% / year 180 deaths 17,516 PYs 4.9% / year 17 deaths 345 PYs 2.87 ( ) INT (n=528 w/ events) 1.3% / year 220 deaths 17, 031 PYs 2.8% / year 34 deaths 1,208 PYs 1.28 ( ) Mortality rate higher in those w hypoglycemia regardless of treatment group HR INT vs STD (95% CI) 1.24 ( ) 0.55 ( ) In those w hypoglycemia, mortality rate lower in INT than STD group PY = Person Years
31 Etiologic Fraction of Deaths Possibly Due to Severe Hypoglycemia Intensive Group Etiologic Fraction: 3.4% X Number of deaths: 254 = Number of deaths potentially attributable to hypoglycemia: 9 Standard Group Etiologic Fraction: 5.4% X Number of deaths: 197 = Number of deaths potentially attributable to hypoglycemia: 11
32 Association of Average A1C with Mortality by Tx Strategy Did the Intensive Patients who died have lower A1C s? Hazard Ratio for 1% higher average updated A1C (95% CI), w group assignment added to other covariates: INT strategy 1.66 (1.46, 1.89) p= STD strategy 1.14 (0.95, 1.38) Interaction between INT and STD: p=0.17 p= Relationships between average A1C and mortality differed between treatment strategies
33 Risk of Death over Range of Ave. A1C Smoothed spline plots with 95% confidence intervals, adjusted for all covariates Steady increase of risk from 6% to 9% A1C in INT strategy Log HR of Mortality Relative to 6% A1C INT STD Excess risk with Average INT vs STD A1Cabove A1C 7%
34 Rates of Death During Treatment over a Range of 1-year Change in A1C Excess risk with INT vs STD strategy occurred when INT participants failed to reduce A1C in year 1 Death rates per year INT STD 0.0 A1C decline 0.5 from 1.0 baseline over months 2.0 (%)
35 ACCORD Conclusions: Main Results In people with longstanding T2DM and either CVD or additional CV risk factors, over average 3.5 years A strategy using currently available therapies to target near-normal A1C levels, compared to a more conventional strategy Increased mortality Did not reduce a composite of major CVD events (primary outcome) (NEJM 358:2545, 2008)
36 ACCORD Conclusions: Subgroups and Hypoglycemia Excess mortality from INT vs STD consistent across numerous pre-specified and ad-hoc BL subgroups Regardless of treatment assignment: Hypoglycemia risk is higher in women, African Americans, those w/ renal complications Hypoglycemia event preceded by missed or nontypical meals Severe hypoglycemia is associated with a higher risk of mortality Although hypoglycemia was higher in INT than STD groups, there is no evidence that the hypoglycemia accounted for the higher mortality in INT
37 ACCORD Conclusions: Achieved A1C Higher risk of death associated with higher average updated A1C, esp. in INT Lower achieved A1C not associated with hypoglycemia events nor with mortality: Excess risk of death in INT group occurred in those whose average achieved A1C was higher than 7% More rapid reduction of A1C not assoc with higher risk of death in INT group Excess risk in INT vs STD occurred when INT participants failed to reduce A1C in year 1 Results suggest that, using an intensive strategy: Some with T2DM can safely achieve A1C levels below 7% Others who do not readily reduce A1C may be at risk if they persist with this strategy
38 ACCORD Double 2 x 2 Factorial Design Intensive (SBP<120) BP Standard (SBP<140) Lipid stain + fibrate vs statin + placebo Group A Group B Intensive Glycemic Treatment (A1C<6%) * Standard Glycemic Treatment (A1C 7-7.9%) * 2362* 2371* 2753* 2765* 10,251 *Primary analyses compare marginals for main effects (ACCORD Study Group, Am J Cardiol 2007;99[suppl]:21i-33i)
39 After Statin therapy.what? 60 yr old man Post-MI x 3 yrs Hypertension- treated BMI 29 HbA1c 7.0% TC 250 LDL 165 TG 250 HDL 35 Non HDL mg simvastatin HbA1c 7.0% TC 170 LDL 95 TG 200 HDL 35 Non HDL 135
40 Trial N Mean SBP < intense Mean SBP > intense CVD Risk Reduction SHEP % Syst-EUR % HOT 1, % UKPDS 1, % ABCD No CVD ADVANCE 11, % mortality Cushman, et al. Am J Cardiol 2007;99[suppl]:44i 55i; Patel, et al. Lancet. 2007;370:
41 Achieved Systolic Pressures Means +/- 95% Confidence Intervals Mean # Meds: Mean # Meds: Mean SBP (mmhg) Years Post-Randomization Intensive Standard
42 ACCORD SBP ADV UKPDS UK Prospective Diabetes Study
43 Current BP target in diabetes <130/80 mmhg If the ACCORD BP trial demonstrates a reduction in major CVD outcomes: Recommended SBP goal in DM may be <120 mm Hg If ACCORD does not show CVD benefits for the lower BP goal, guidelines may be changed to reflect the evidence from ADVANCE supporting a higher goal (like systolic135 mmhg).
A Fork in the Road: Navigating Through New Terrain
A Fork in the Road: Navigating Through New Terrain Carol Hatch Wysham, MD Clinical Associate Professor of Medicine University of Washington School of Medicine Section Head, Rockwood Center for Diabetes
More informationDiabetes Guidelines in View of Recent Clinical Trials Are They Still Applicable?
Diabetes Guidelines in View of Recent Clinical Trials Are They Still Applicable? Jay S. Skyler, MD, MACP Division of Endocrinology, Diabetes, and Metabolism and Diabetes Research Institute University of
More informationUpdate on CVD and Microvascular Complications in T2D
Update on CVD and Microvascular Complications in T2D Jay S. Skyler, MD, MACP Division of Endocrinology, Diabetes, and Metabolism and Diabetes Research Institute University of Miami Miller School of Medicine
More informationThe Diabetes Link to Heart Disease
The Diabetes Link to Heart Disease Anthony Abe DeSantis, MD September 18, 2015 University of WA Division of Metabolism, Endocrinology and Nutrition Oswald Toosweet Case #1 68 yo M with T2DM Diagnosed DM
More informationMicrovascular Complications in Diabetes:
Microvascular Complications in Diabetes: Perspectives on Glycemic Control to Prevent Microvascular Complications Discussion Outline: Glycemia and Microvascular Compliations Clinical Trials - A Brief History
More informationComparing the use of SMBG vs. CGM data to Optimize Glucose Control in T2DM
Comparing the use of SMBG vs. CGM data to Optimize Glucose Control in T2DM For the first time using CGM to assess glucose control achieved in both groups Richard M. Bergenstal, MD International Diabetes
More informationMacrovascular Residual Risk. What risk remains after LDL-C management and intensive therapy?
Macrovascular Residual Risk What risk remains after LDL-C management and intensive therapy? Defining Residual Vascular Risk The risk of macrovascular events and microvascular complications which persists
More informationSlide 1. Slide 2. Slide 3. A Fork in the Road: Navigating Through New Terrain. Diabetes Standards of Care Then and Now
Slide 1 A Fork in the Road: Navigating Through New Terrain Carol Hatch Wysham, MD Clinical Associate Professor of Medicine University of Washington School of Medicine Section Head, Rockwood Center for
More informationDiabetes Mellitus: Implications of New Clinical Trials and New Medications
Diabetes Mellitus: Implications of New Clinical Trials and New Medications Estimates of Diagnosed Diabetes in Adults, 2005 Alka M. Kanaya, MD Asst. Professor of Medicine UCSF, Primary Care CME October
More informationDiabete: terapia nei pazienti a rischio cardiovascolare
Diabete: terapia nei pazienti a rischio cardiovascolare Giorgio Sesti Università Magna Graecia di Catanzaro Cardiovascular mortality in relation to diabetes mellitus and a prior MI: A Danish Population
More informationWhy is Earlier and More Aggressive Treatment of T2 Diabetes Better?
Blood glucose (mmol/l) Why is Earlier and More Aggressive Treatment of T2 Diabetes Better? Disclosures Dr Kennedy has provided CME, been on advisory boards or received travel or conference support from:
More informationThe Diamond Study: Continuous Glucose Monitoring In Patients on Mulitple Daily Insulin Injections
8/5/217 The Diamond Study: Continuous Glucose Monitoring In Patients on Mulitple Daily Insulin Injections Richard M. Bergenstal, MD Executive Director International Diabetes Center at Park Nicollet Minneapolis,
More informationCedars Sinai Diabetes. Michael A. Weber
Cedars Sinai Diabetes Michael A. Weber Speaker Disclosures I disclose that I am a Consultant for: Ablative Solutions, Boston Scientific, Boehringer Ingelheim, Eli Lilly, Forest, Medtronics, Novartis, ReCor
More informationESC GUIDELINES ON DIABETES AND CARDIOVASCULAR DISEASES
ESC GUIDELINES ON DIABETES AND CARDIOVASCULAR DISEASES Pr. Michel KOMAJDA Institute of Cardiology - IHU ICAN Pitie Salpetriere Hospital - University Pierre and Marie Curie, Paris (France) DEFINITION A
More informationDiabetes Mellitus: A Cardiovascular Disease
Diabetes Mellitus: A Cardiovascular Disease Nestoras Mathioudakis, M.D. Assistant Professor of Medicine Division of Endocrinology, Diabetes, & Metabolism September 30, 2013 1 The ABCs of cardiovascular
More informationMisperceptions still exist that cardiovascular disease is not a real problem for women.
Management of Cardiovascular Risk Factors in the Cynthia A., MD University of California, San Diego ARHP 9/19/08 Disclosures Research support Wyeth, Lilly, Organon, Novo Nordisk, Pfizer Consultant fees
More informationOral Hypoglycemics and Risk of Adverse Cardiac Events: A Summary of the Controversy
Oral Hypoglycemics and Risk of Adverse Cardiac Events: A Summary of the Controversy Jeffrey Boord, MD, MPH Advances in Cardiovascular Medicine Kingston, Jamaica December 7, 2012 VanderbiltHeart.com Outline
More informationGlucose Control and Prevention of Cardiovascular Disease
Glucose Control and Prevention of Cardiovascular Disease Dr Peter A Senior BMedSci MBBS PhD FRCP(E) Associate Professor, Director Division of Endocrinology, University of Alberta Diabetes Update+, March
More informationT. Suithichaiyakul Cardiomed Chula
T. Suithichaiyakul Cardiomed Chula The cardiovascular (CV) continuum: role of risk factors Endothelial Dysfunction Atherosclerosis and left ventricular hypertrophy Myocardial infarction & stroke Endothelial
More informationThe Clinical Unmet need in the patient with Diabetes and ACS
The Clinical Unmet need in the patient with Diabetes and ACS Professor Kausik Ray (UK) BSc(hons), MBChB, MD, MPhil, FRCP (lon), FRCP (ed), FACC, FESC, FAHA Diabetes is a global public health challenge
More information1. How does the response to therapy compare in elderly versus middle age adults with diabetes in a randomized trial?
Jeff D. Williamson, MD, MHS Chief, Geriatric Medicine Sticht Center on Aging 1. How does the response to therapy compare in elderly versus middle age adults with diabetes in a randomized trial? 2. Are
More informationGlycemic control a matter of life and death
Glycemic control a matter of life and death Linda Garcia Mellbin MD PhD Specialist in Cardiology & Internal medicine Dep of Cardiology Karolinska University Hospital /Karolinska Institutet Mortality (%)
More informationHow to Reduce CVD Complications in Diabetes?
How to Reduce CVD Complications in Diabetes? Chaicharn Deerochanawong M.D. Diabetes and Endocrinology Unit Department of Medicine Rajavithi Hospital, Ministry of Public Health Framingham Heart Study 30-Year
More informationThe ABCs (A1C, BP and Cholesterol) of Diabetes
The ABCs (A1C, BP and Cholesterol) of Diabetes Gregg Simonson, PhD Director, Professional Training and Consulting International Diabetes Center; Adjunct Assistant Professor, University of Minnesota Department
More informationComplications of Diabetes: Screening and Prevention
Complications of Diabetes: Screening and Prevention Dr Steve Cleland Consultant Physician GGH and QEUH Diabetes Staff Education Course June 17 Diabetic Complications Microvascular: Retinopathy Nephropathy
More informationGlucose and CV disease
Glucose and CV disease Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic,
More informationADVANCE post trial ObservatioNal Study
Hot Topics in Diabetes 50 th EASD, Vienna 2014 ADVANCE post trial ObservatioNal Study Sophia Zoungas The George Institute The University of Sydney Rationale and Study Design Sophia Zoungas The George Institute
More informationThe target blood pressure in patients with diabetes is <130 mm Hg
Controversies in hypertension, About Diabetes diabetes and and metabolic Cardiovascular syndrome Risk ESC annual congress August 29, 2011 The target blood pressure in patients with diabetes is
More informationCardiovascular Management of a Patient with Diabetes
Cardiovascular Management of a Patient with Diabetes Dr Jeremy Krebs Clinical Leader Endocrinology and Diabetes Wellington Hospital Summary People with diabetes take a lot of medication Compliance and
More informationThe Latest Generation of Clinical
The Latest Generation of Clinical Guidelines: HTN and HLD Dave Brackett Clinical Guideline Purpose Uniform approach Awareness of key details Diagnosis Treatment Monitoring Evidence based approach Inform
More informationDiabetes and the Heart
Diabetes and the Heart Jeffrey Boord, MD, MPH Advances in Cardiovascular Medicine Kingston, Jamaica December 6, 2012 Outline Screening for diabetes in patients with CAD Screening for CAD in patients with
More informationNew Lipid Guidelines. PREVENTION OF CARDIOVASCULAR DISEASE IN WOMEN: Implications of the New Guidelines for Hypertension and Lipids.
PREVENTION OF CARDIOVASCULAR DISEASE IN WOMEN: Implications of the New Guidelines for Hypertension and Lipids Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Disclosure No relevant
More informationTreating Hypertension in Individuals with Diabetes
Treating Hypertension in Individuals with Diabetes Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any
More informationCauses of death in Diabetes
Rates of CV events in Diabetes patients Respiratory4.2 Cancer 7.6 Diabetes 1.3 CV disease 17.3 Causes of death in Diabetes 250 200 150 100 50 0 per 10,000 person-years 97 151 243 Framingham 5 X increase
More informationegfr > 50 (n = 13,916)
Saxagliptin and Cardiovascular Risk in Patients with Type 2 Diabetes Mellitus and Moderate or Severe Renal Impairment: Observations from the SAVOR-TIMI 53 Trial Supplementary Table 1. Characteristics according
More informationDisclosures. Diabetes and Cardiovascular Risk Management. Learning Objectives. Atherosclerotic Cardiovascular Disease
Disclosures Diabetes and Cardiovascular Risk Management Tony Hampton, MD, MBA Medical Director Advocate Aurora Operating System Advocate Aurora Healthcare Downers Grove, IL No conflicts or disclosures
More informationCurrent Updates & Challenges In Managing Diabetes in CVD
Current Updates & Challenges In Managing Diabetes in CVD Preventive Cardiovascular Conference 2016 Instituit Jantung Negara 12 th November 2016 Nor Azmi Kamaruddin Diabetes Clinic Department of Medicine
More informationDiabetes and Hypertension
Diabetes and Hypertension William C. Cushman, MD, FAHA, FACP, FASH Chief, Preventive Medicine, Veterans Affairs Medical Center Professor, Preventive Medicine, Medicine, and Physiology University of Tennessee
More informationJohn J.P. Kastelein MD PhD Professor of Medicine Dept. of Vascular Medicine Academic Medial Center / University of Amsterdam
Latest Insights from the JUPITER Study John J.P. Kastelein MD PhD Professor of Medicine Dept. of Vascular Medicine Academic Medial Center / University of Amsterdam Inflammation, hscrp, and Vascular Prevention
More informationDiabetes and Cardiovascular Risk Management Denise M. Kolanczyk, PharmD, BCPS-AQ Cardiology
Diabetes and Cardiovascular Risk Management Denise M. Kolanczyk, PharmD, BCPS-AQ Cardiology Disclosures In compliance with the accrediting board policies, the American Diabetes Association requires the
More informationBlood Pressure Targets in Diabetes
Stockholm, 29 th August 2010 ESC Meeting Blood Pressure Targets in Diabetes Peter M Nilsson, MD, PhD Department of Clinical Sciences University Hospital, Malmö Sweden Studies on BP in DM2 ADVANCE RCT (Lancet
More informationSystolic Blood Pressure Intervention Trial (SPRINT)
09:30-09:50 2016.4.15 Systolic Blood Pressure Intervention Trial (SPRINT) IN A NEPHROLOGIST S VIEW Sejoong Kim Seoul National University Bundang Hospital Current guidelines for BP control Lowering BP
More informationTreating Hypertension in 2018: What Makes the Most Sense Today?
Treating Hypertension in 2018: What Makes the Most Sense Today? Daniel Blanchard, MD Professor of Medicine UC San Diego Cardiovascular Center La Jolla, California 1 2 Speaker Disclosures Consultant and/or
More informationManagement of Diabetes Mellitus: A Primary Care Perspective
Management of Diabetes Mellitus: A Primary Care Perspective Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest Screening
More informationRole of SMBG in Non-Insulin Treated Subjects with T2DM Richard M. Bergenstal, MD
Role of SMBG in Non-Insulin Treated Subjects with T2DM Richard M. Bergenstal, MD International Diabetes Center and Health Services University of Minnesota Minneapolis, MN richard.bergenstal@parknicollet.com
More informationMacrovascular Disease in Diabetes
Macrovascular Disease in Diabetes William R. Hiatt, MD Professor of Medicine/Cardiology University of Colorado School of Medicine President, CPC Clinical Research Conflicts CPC Clinical Research (University-based
More informationAggressive Lipid Management for Diabetes
Aggressive Lipid Management for Diabetes Practical Ways to Achieve Targets in Diabetes Care Keystone, CO July 16, 2011 Robert H. Eckel, M.D. Professor of Medicine Professor of Physiology and Biophysics
More informationHypertension targets: sorting out the confusion. Brian Rayner, Division of Nephrology and Hypertension, University of Cape Town
Hypertension targets: sorting out the confusion Brian Rayner, Division of Nephrology and Hypertension, University of Cape Town Historical Perspective The most famous casualty of this approach was the
More informationHypertension in 2015: SPRINT-ing ahead of JNC-8. MAJ Charles Magee, MD MPH FACP Director, WRNMMC Hypertension Clinic
Hypertension in 2015: SPRINT-ing ahead of JNC-8 MAJ Charles Magee, MD MPH FACP Director, WRNMMC Hypertension Clinic Conflits of interest? None Disclaimer The opinions contained herein are not to be considered
More informationDiabetes Day for Primary Care Clinicians Advances in Diabetes Care
Diabetes Day for Primary Care Clinicians Advances in Diabetes Care Elliot Sternthal, MD, FACP, FACE Chair New England AACE Diabetes Day Planning Committee Welcome and Introduction This presentation will:
More informationPrevention of complications: are we winning or losing the battle. Naveed Sattar Professor of Metabolic Medicine
Prevention of complications: are we winning or losing the battle Naveed Sattar Professor of Metabolic Medicine Duality of Interest Declaration Consultant or speaker for: Amgen, AstraZeneca, Boehringer
More informationManagement of Diabetes Mellitus: A Primary Care Perspective. Screening for Diabetes Advantages of HbA1c as a Diagnostic Test
Management of Diabetes Mellitus: A Primary Care Perspective Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest Screening
More informationPreventing Serious Health Consequences of Type 2 Diabetes
Preventing Serious Health Consequences of Type 2 Diabetes The Evidence Hertzel C. Gerstein MD MSc FRCPC Professor and Population Health Institute Chair in Diabetes Research McMaster University and Hamilton
More informationPlacebo-Controlled Statin Trials Prevention Of CVD in Women"
MANAGEMENT OF HIGH BLOOD CHOLESTEROL: IMPLICATIONS OF THE NEW GUIDELINES Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest
More informationCase Presentation. Rafael Bitzur The Bert W Strassburger Lipid Center Sheba Medical Center Tel Hashomer
Case Presentation Rafael Bitzur The Bert W Strassburger Lipid Center Sheba Medical Center Tel Hashomer Case Presentation 50 YO man NSTEMI treated with PCI 1 month ago Medical History: Obesity: BMI 32,
More informationDiabetes and New Meds for Cardiovascular Risk Reduction. F. Dwight Chrisman, MD, FACC. Disclosures: BI Boehringer Ingelheim speaker
Diabetes and New Meds for Cardiovascular Risk Reduction F. Dwight Chrisman, MD, FACC Disclosures: BI Boehringer Ingelheim speaker 1 Prevalence of DM DM state specific prevalence 2006 4%-6% 6-8% 8-10% 10-12%
More informationManagement of Lipid Disorders and Hypertension: Implications of the New Guidelines
Management of Lipid Disorders and Hypertension Management of Lipid Disorders and Hypertension: Implications of the New Guidelines Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine
More informationObjectives. Describe results and implications of recent landmark hypertension trials
Hypertension Update Daniel Schwartz, MD Assistant Professor of Medicine Associate Medical Director of Heart Transplantation Temple University School of Medicine Disclosures I currently have no relationships
More informationALLHAT Role of Diuretics in the Prevention of Heart Failure - The Antihypertensive and Lipid- Lowering Treatment to Prevent Heart Attack Trial
1 ALLHAT Role of Diuretics in the Prevention of Heart Failure - The Antihypertensive and Lipid- Lowering Treatment to Prevent Heart Attack Trial Davis BR, Piller LB, Cutler JA, et al. Circulation 2006.113:2201-2210.
More informationUpdate on Diabetes. Ketan Dhatariya. Why it s Not Just About Glucose Lowering Any More. Consultant in Diabetes NNUH
Update on Diabetes Why it s Not Just About Glucose Lowering Any More Ketan Dhatariya Consultant in Diabetes NNUH The Story So Far.. DCCT Retinopathy Neuropathy Nephropathy Intensive glucose control in
More informationThe EMPA-REG OUTCOME trial: Design and results. David Fitchett, MD University of Toronto, Canada
The EMPA-REG OUTCOME trial: Design and results David Fitchett, MD University of Toronto, Canada Asian Cardio Diabetes Forum April 23 24, 2016 Kuala Lumpur, Malaysia Life Expectancy Is Reduced by ~12 Years
More informationNew Recommendations for the Treatment of Hypertension: From Population Salt Reduction to Personalized Treatment Targets
New Recommendations for the Treatment of Hypertension: From Population Salt Reduction to Personalized Treatment Targets Sidney C. Smith, Jr. MD, FACC, FAHA Professor of Medicine/Cardiology University of
More informationT2 Diabetes in Sep-16. Stephen Leow Disclosures. Why do we treat diabetes? Agenda. Targets
Stephen Leow Disclosures I have received honoraria, sat on the advisory boards or received grants from Novo Nordisk, Sanofi Aventis, Eli Lilly, Boehringer Ingleheim, Jansenn Cilag, Mundipharma, BioCSL,
More informationAntihypertensive Trial Design ALLHAT
1 U.S. Department of Health and Human Services Major Outcomes in High Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic National Institutes
More informationDu gusts is megl che one. Edoardo Mannucci
Du gusts is megl che one Edoardo Mannucci Conflitti di interessi Negli ultimi due anni, E. Mannucci ha ricevuto compensi per relazioni e/o consulenze da: Abbott, AstraZeneca, Boehringer Ingelheim, Eli
More informationCURRENT CONTROVERSIES IN DIABETES CARE
CURRENT CONTROVERSIES IN DIABETES CARE Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest Diabetes Mellitus: U.S. Impact
More informationDecline in CV-Mortality
Lipids id 2013 What s Changed? Christopher Granger, MD Disclosure Research contracts: AstraZeneca, GSK, Merck, Sanofi- Aventis, BMS, Pfizer, The Medicines Company, Medtronic Foundation, and Boehringer
More informationJNC 8 -Controversies. Sagren Naidoo Nephrologist CMJAH
JNC 8 -Controversies Sagren Naidoo Nephrologist CMJAH Joint National Committee (JNC) Panel appointed by the National Heart, Lung, and Blood Institute (NHLBI) First guidelines (JNC-1) published in 1977
More informationPlacebo-Controlled Statin Trials MANAGEMENT OF HIGH BLOOD CHOLESTEROL MANAGEMENT OF HIGH BLOOD CHOLESTEROL: IMPLICATIONS OF THE NEW GUIDELINES
MANAGEMENT OF HIGH BLOOD CHOLESTEROL: IMPLICATIONS OF THE NEW GUIDELINES Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest
More informationGlucose Control: Does it lower CV risk?
Glucose Control: Does it lower CV risk? Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic,
More informationEvidence-Based Glucose Management in Type 2 Diabetes
Evidence-Based Glucose Management in Type 2 Diabetes James R. Gavin III, MD, PhD CEO and Chief Medical Officer Healing Our Village, Inc. Clinical Professor of Medicine Emory University School of Medicine
More information1/28/2014. The Metabolic Syndrome: Early History. Insulin Resistance: Early Diagnosis and Treatment to Prevent Cardiovascular Disease
: Early Diagnosis and Treatment to Prevent Cardiovascular Disease Henry N. Ginsberg, M.D. Irving Professor of Medicine Columbia University College of Physicans and Surgeons The Metabolic Syndrome: Early
More informationManagement of Type 2 Diabetes Cardiovascular Outcomes Trials Tom Blevins MD Texas Diabetes and Endocrinology Austin, Texas
Management of Type 2 Diabetes Cardiovascular Outcomes Trials 2018 Tom Blevins MD Texas Diabetes and Endocrinology Austin, Texas Speaker Disclosure Dr. Blevins has disclosed that he has received grant support
More informationThe New Hypertension Guidelines
The New Hypertension Guidelines Joseph Saseen, PharmD Professor and Vice Chair, Department of Clinical Pharmacy University of Colorado Anschutz Medical Campus Disclosure Joseph Saseen reports no conflicts
More informationDiabetes Treatment Update
Diabetes Treatment Update Timothy C. Evans, MD PhD FACP University of Washington Department of Medicine Disclosure: Dr. Evans has no significant financial interest in any of the products or manufacturers
More information1. Albuminuria an early sign of glomerular damage and renal disease. albuminuria
1. Albuminuria an early sign of glomerular damage and renal disease albuminuria Cardio-renal continuum REGRESS Target organ damage Asymptomatic CKD New risk factors Atherosclerosis Target organ damage
More informationDisclosures. Dr. Scirica has also served as a consultant for Lexicon, Arena, Gilead, and Eisai.
Disclosures Benjamin M. Scirica, MD, MPH, is employed by the TIMI Study Group, which has received research grants from Abbott, AstraZeneca, Amgen, Bayer HealthCare Pharmaceuticals, Bristol-Myers Squibb,
More informationCANADIAN STROKE BEST PRACTICE RECOMMENDATIONS. Prevention of Stroke Evidence Tables Diabetes Management
CANADIAN STROKE BEST PRACTICE RECOMMENDATIONS Diabetes Management Coutts S, Wein T (Writing Group Chairs) on Behalf of the PREVENTION of STROKE Writing Group 2014 Heart and Stroke Foundation November 2014
More informationHypertension Management in Diabetic Patients
Hypertension Management in Diabetic Patients Park, Chang G, MD, PhD Cardiovascular Center, Guro Hospital, Korea University Medical School Contents (Treatment of 2 Cases) Type 2 Diabetes Mellitus Hypertension
More informationReview of guidelines for management of dyslipidemia in diabetic patients
2012 international Conference on Diabetes and metabolism (ICDM) Review of guidelines for management of dyslipidemia in diabetic patients Nan Hee Kim, MD, PhD Department of Internal Medicine, Korea University
More informationTrial to Reduce. Aranesp* Therapy. Cardiovascular Events with
Trial to Reduce Cardiovascular Events with Aranesp* Therapy John J.V. McMurray, Hajime Uno, Petr Jarolim, Akshay S. Desai, Dick de Zeeuw, Kai-Uwe Eckardt, Peter Ivanovich, Andrew S. Levey, Eldrin F. Lewis,
More informationALLHAT. ALLHAT Antihypertensive Trial Results by Baseline Diabetic & Fasting Glucose Status
ALLHAT Antihypertensive Trial Results by Baseline Diabetic & Fasting Glucose Status 1 Introduction and Background Clinical trials have reported reduction in CV events with diuretics, CCBs, ACE inhibitors,
More informationIndividualized Treatment Goals for Optimal Long-Term Health Outcomes among Patients with Type 2 Diabetes Mellitus
1 Dissertation Title Page: Individualized Treatment Goals for Optimal Long-Term Health Outcomes among Patients with Type 2 Diabetes Mellitus Qian Shi, MPH, PhD candidate Department of Global Health Management
More informationA nationwide population-based study. Pai-Feng Hsu M.D. Shao-Yuan Chuang PhD
The Association of Clinical Symptomatic Hypoglycemia with Cardiovascular Events and Total Death in Type 2 Diabetes Mellitus A nationwide population-based study Pai-Feng Hsu M.D. Shao-Yuan Chuang PhD Taipei
More informationADVANCE Endpoints. Primary outcome. Secondary outcomes
ADVANCE Trial-NEJM 11,140 type 2 patients with h/o microvascular or macrovascular disease or 1 vascular disease risk factor Control A1c to 6.5% vs standard tx Intensive arm received gliclazide XL 30 to
More informationPractical Diabetes. Nic Crook. (and don t use so many charts) Kuirau Specialists 1239 Ranolf Street Rotorua. Rotorua Hospital Private Bag 3023 Rotorua
Practical Diabetes (and don t use so many charts) Nic Crook Rotorua Hospital Private Bag 3023 Rotorua Kuirau Specialists 1239 Ranolf Street Rotorua Worldwide rates of diabetes mellitus: predictions 80
More informationTreatment to reduce cardiovascular risk: multifactorial management
Treatment to reduce cardiovascular risk: multifactorial management Matteo Anselmino, MD PhD Assistant Professor San Giovanni Battista Hospital Division of Cardiology, Department of Internal Medicine University
More informationIMPROVED DIAGNOSIS OF TYPE 2 DIABETES AND TAILORING MEDICATIONS
IMPROVED DIAGNOSIS OF TYPE 2 DIABETES AND TAILORING MEDICATIONS Dr Bidhu Mohapatra, MBBS, MD, FRACP Consultant Physician Endocrinology and General Medicine Introduction 382 million people affected by diabetes
More informationReview. Hyperglycemia, dyslipidemia and hypertension in older people with diabetes: the benefits of cardiovascular risk reduction
Review Hyperglycemia, dyslipidemia and hypertension in older people with diabetes: the benefits of cardiovascular risk reduction Diabetes mellitus is increasingly recognized as an essentially vascular
More informationLDL cholesterol and cardiovascular outcomes?
LDL cholesterol and cardiovascular outcomes? Prof Kausik Ray, BSc (hons), MBChB, FRCP, MD, MPhil (Cantab), FACC, FESC Professor of Cardiovascular Disease Prevention St Georges University of London Honorary
More informationFOURIER: Enough Evidence to Justify Widespread Use? Did It fulfill Its Expectations?
FOURIER: Enough Evidence to Justify Widespread Use? Did It fulfill Its Expectations? CVCT Washington, DC November 3, 2017 Marc S. Sabatine, MD, MPH Chairman, TIMI Study Group Lewis Dexter, MD, Distinguished
More informationEugene Barrett M.D., Ph.D. University of Virginia 6/18/2007. Diagnosis and what is it Glucose Tolerance Categories FPG
Diabetes Mellitus: Update 7 What is the unifying basis of this vascular disease? Eugene J. Barrett, MD, PhD Professor of Internal Medicine and Pediatrics Director, Diabetes Center and GCRC Health System
More informationDiabetes new challenges, new agents, new order
Diabetes new challenges, new agents, new order Ken Earle St Georges University Hospitals NHS Foundation Trust Overview Cardiovascular disease unmet needs Treating evident and residual risk Integrating
More informationUPDATES IN AMBULATORY MEDICINE ERIK RIESSEN, MD, FACP INTERMOUNTAIN MEDICAL CENTER OUTPATIENT INTERNAL MEDICINE RESIDENCY CLINIC
UPDATES IN AMBULATORY MEDICINE ERIK RIESSEN, MD, FACP INTERMOUNTAIN MEDICAL CENTER OUTPATIENT INTERNAL MEDICINE RESIDENCY CLINIC DISCLOSURES: I have no conflict-of-interest disclosures UPDATES: THE STRUGGLE
More informationTerapia con agonisti GLP1 e outcome cardiovascolare. Edoardo Mannucci
Terapia con agonisti GLP e outcome cardiovascolare Edoardo Mannucci Conflitti di interessi Negli ultimi due anni, E. Mannucci ha ricevuto compensi per relazioni e/o consulenze da: Abbott, AstraZeneca,
More informationHanyang University Guri Hospital Chang Beom Lee
Hanyang University Guri Hospital Chang Beom Lee Meal prayer, Van Brekelenkam 17 th C Introduction 2012 ADA/EASD Position Statement Proper Patients for Pioglitazone β-cell Preservation by Pioglitazone Benefit
More informationLATE BREAKING STUDIES IN DM AND CAD. Will this change the guidelines?
LATE BREAKING STUDIES IN DM AND CAD Will this change the guidelines? Objectives 1. Discuss current guidelines for prevention of CHD in diabetes. 2. Discuss the FDA Guidance for Industry regarding evaluating
More informationKidney and heart: dangerous liaisons. Luis M. RUILOPE (Madrid, Spain)
Kidney and heart: dangerous liaisons Luis M. RUILOPE (Madrid, Spain) Type 2 diabetes and renal disease: impact on cardiovascular outcomes The "heavyweights" of modifiable CVD risk factors Hypertension
More informationA factorial randomized trial of blood pressure lowering and intensive glucose control in 11,140 patients with type 2 diabetes
A factorial randomized trial of blood pressure lowering and intensive glucose control in 11,140 patients with type 2 diabetes Hypotheses: Among individuals with type 2 diabetes, the risks of major microvascular
More informationDiabetic Management of the Cardiac Patient
Diabetic Management of the Cardiac Patient Dr Peter A Senior BMedSci MBBS PhD FRCP(E) Associate Professor, Director Division of Endocrinology, University of Alberta Disclosures Grants/Research Support:
More information