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

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

2 Revascularisation of patients with diabetes Stable CAD medical therapy or revascularisation Revascularisation PCI or CABG PCI Bare Metal or Drug Eluting Stent Acute coronary syndromes Conclusions

3 Revascularisation of patients with diabetes Stable CAD medical therapy or revascularisation

4 Type 2 Diabetes + stable CAD + angiography n = Follow Up: 5.3 years Intense medical treatment + Revascularisation vs. Intense medical treatment only (BARI 2D Study Group. N Engl J Med 2009:360:2503)

5 BARI 2 D Patient population Inclusion criteria 1. Diabetes type 2 2. Coronary artery disease 50% epicardial stenosis and a positive stress test 70% epicardial stenosis and classical angina Exclusion criteria 1. Need for immediate revascularisation 2. Left main coronary artery disease 3. Kidney or hepatic dysfunction 4. HbA1c >13% 5. Heart failure; NYHA III, IV 6. Revascularisaton <12 months (BARI 2D Study Group. N Engl J Med 2009:360:2503)

6 BARI 2 D Optimal medical therapy (targets applied in all patients) 1. HbA1c <7.0% 2. LDL <2,6 mmol/l (100mg/dl) 3. BP <130/80 mmhg 4. Counseling smoking cessation weight loss regular exercise 5. Monthly visits first 6 months (BARI 2D Study Group. N Engl J Med 2009:360:2503)

7 BARI 2 D 2 x 2 factorial design (BARI 2D Study Group. N Engl J Med 2009:360:2503)

8 BARI 2 D Revascularisation Patients randomised to revascularisation Intervention within 4 weeks Patients randomised to medical treatment Progression of angina Acute coronary syndrome Severe ischemia (BARI 2D Study Group. N Engl J Med 2009:360:2503)

9 Survival (%) BARI 2 D Survival Revascularisation vs. Medical therapy Revascularisation Medical therapy % p = 0.97 Follow up (years) (BARI 2D Study Group. N Engl J Med 2009:360:2503)

10 BARI 2 D Freedom major CV-events (Death, MI, Stroke) Revascularisation vs. Medical therapy Survival (%) Event free survival (%) Revascularisation % Revascularisation Prompt revascularisation did not improve 77.2 Medical therapy Medical therapy outcome compared to medical treatment in 75.9 patients with type 2 diabetes with stable CAD on intense medical treatment p = 0.97 p = % of medical patients revascularised during follow up Follow up (years) (BARI 2D Study Group. N Engl J Med 2009:360:2503)

11 BARI 2 D Survival Insulin sensitising vs. Insulin providing therapy Survival (%) Insulin sensitisation Insulin provision % p = 0.13 Follow up (years) (BARI 2D Study Group. N Engl J Med 2009:360:2503)

12 Revascularisation of patients with diabetes Stable CAD medical therapy or revascularisation Revascularisation PCI or CABG PCI Bare Metal or Drug Eluting Stent

13 Event free survival (%) BARI 2 D Freedom from major CV-events in the CABG stratum Revascularisation Medical therapy prompt p revascularisation = 0.01 decreased % Compared to intense medical treatment alone major CV events in the CABG stratum Follow up (years) (BARI 2D Study Group. N Engl J Med 2009:360:2503)

14 CABG compared with PCI for multivessel disease collaborative analysis of individual patient data from 10 randomised trials Mortality (%) 35 PCI diabetes All Bare Metal Stents Follow up (years) CABG diabetes CABG no diabetes PCI no diabetes (Hlatky et al Lancet 2009; 373:1190)

15 Coronary Artery Revascularisation DIAbetes trial Diabetes n = 510; Randomized CABG or PCI; DES 71% CABG PCI (ESC annual congress 2008)

16 Diabetes and revascularisation PCI or CABG What do we need RCT CABG vs PCI/DES Patients with diabetes Ongoing Clinically relevant endpoints Outcome not known (Farkouh et al Am Heart J 2008; 155:215)

17 Mortality (%) Survival among PCI pa tients by diabetic state From the Swedish PCI registry (n= 57708; DM = STEMI + DM Non-STEMI + DM STEMI no DM Stable AP + DM Non-STEMI no DM Stable AP - no DM Years after PCI No. at Risk DM No DM (Norhammar et al Eurointervention 2010; 8: 891)

18 Revascularisation of patients with diabetes Stable CAD medical therapy or revascularisation Revascularisation Type 2 Diabetes + stable PCI or CAD CABG + angiography PCI Bare Metal or n = Drug Eluting Stent Follow Up: 5.3 years Acute coronary syndromes Intense medical treatment + Revascularisation vs. Intense medical treatment only

19 FRISC II One year outcome Early revascularisation in ACS (n=1222; DM = 155) MI or Death Death Invasive Non-invasive Event rate (%) OR = 0.72 p = OR = 0.63 p = Event rate (%) 0 No diabetes Diabetes No diabetes Diabetes OR = 0.52 p = OR = 0.69 p = NS (Norhammar et al J Am Coll Card 2004; 43; 585)

20 Cumulative event free rate Multifactorial Intervention in type 2 Diabetes Euro Heart Survey Diabetes and the Heart 1,00 0,99 Impact of Coronary Interventions on 1-year mortality 0,98 0,97 No DM RV + No DM RV - 0,96 0,95 0,94 DM RV + 0,93 0,92 0, Time of follow up (days) (Anselmino et al Europ J Cardiovasc Prev Rehab 2008;15:216) DM RV -

21 Multifactorial Intervention in type 2 Diabetes Euro Heart Survey Diabetes and the Heart Number Needed to Treat with EBM and Revascularisation Evidence Based Medicine Revascularization Treatment type Diabetes NNT to avoid one event Fatal Cardiovascular Evidence Based No Medicine Yes Revascularisation No Yes (Anselmino et al Europ J Cardiovasc Prev Rehab 2008;15:216)

22 Revascularisation of patients with diabetes Stable CAD medical therapy or revascularisation Revascularisation Type 2 Diabetes + stable PCI or CAD CABG + angiography PCI Bare Metal or n = Drug Eluting Stent Follow Up: 5.3 years Acute coronary syndromes Intense Conclusions medical treatment + Revascularisation vs. Intense medical treatment only

23 Prevention of Cardiovascular Disease in Managing Patients with Diabetes Patients with Diabetes Conclusions Conclusions Optimal medical therapy without routine PCI or CABG can safely be implemented as initial management in a majority of patients with stable CAD Patients seems to benefit by prompt revascularisation if deemed in need of CABG All patients with ACS are at high risk and should undergo an early angiography and revascularisation (<24-72 hours) CABG strongly advocated in patients with multivessel disease and high Syntax score (>33)

24 Master Class in Preventive Cardiology Focus on Diabetes and Cardiovascular Disease Geneva April Thanks for the attention!!!