Diabetes en Revascularisatie

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Diabetes en Revascularisatie

• Menko-Jan de Boer en Lars Rydén
• Namens de Task Force on Diabetes and
  Cardiovascular Diseases
• of the European Society of Cardiology (ESC) and
  the European
• Association for the Study of Diabetes (EASD)
• NVVC
• 17 April 2008

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ESC/EASD Guidelines Diabetes, prediabetes and
cardiovascular disease
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ESC/EASD Guidelines Diabetes, pre-diabetes and
cardiovascular disease
Trials addressing diabetes and revascularisation f
or multivessel disease
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ESC/EASD Guidelines Diabetes, prediabetes and
cardiovascular disease
Revascularisation of diabetic patients
with multivessel disease in the stent area
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Blood glucose - a continuous risk factor for
cardiovascular disease
Relative Risk
meta-analysis over 12 studies
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2.5
2
1.5
1
4
6
8
10
12
(mmol/L)
2h post load glucose (mmol/l)
Coutinho et at. Diab Care 199922659
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The prevalence of hyperglycaemia (DM or IGH)
estimated in patients with coronary artery disease
IGT
isolated IFG
Bartnik M et a. Eur Heart J 2004 251880
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Management of diabetes and glucose control
before, during and after PCI and CABG
Diabetes and coronary revascularization Bypass
surgery versus PCI Adjunctive therapy Revasculariz
ation in acute coronary syndromes Glucose
control Unresolved issues
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Management of diabetes and glucose control
before, during and after PCI and CABG
Diabetes and coronary revascularization
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Diabetes and coronary revascularization
Registry study - Duke University data base n 3
220 (diabetes 24) with 2-3 VD. Interventions
1984 - 1990
(Barness et al Circulation 1997962551)
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Diabetes and coronary revascularization
The BARI randomized trial comparing CABG and
PCI Patients n 1829 Diabetes n353 (19)
77 CABG No diabetes 77 PCI No diabetes
58 CABG Diabetes 45 PCI Diabetes
Diabetes No PCI vs. CABG p0.59 Yes
PCI vs. CABG p0.025
(The BARI investigators JACC 2007 491600)
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Diabetes and coronary revascularization
Coronary interventions in patients with vs.
without diabetes

• Coronary Bypass Surgery
• Higher mortality
• More frequent complications
• infections, delayed wound healing
• Percutanous coronary angioplasty
• Higher mortality
• High restenosis rate
• Increased rate of stent thrombosis
• More frequent repeat revascularizations

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Management of diabetes and glucose control
before, during and after PCI and CABG
Diabetes and coronary revascularization By pass
surgery versus PCI
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By pass surgery by diabetic state
North American retrospective cohort study 30 day
mortality and morbidity in CABG No diabetes n
105 123 Diabetes n 31663 (28)
Diabetes No Yes Adjusted OR
Variable
Mortality 2.7 3.7 1.23 (1.15-1.32) Morbidity 9.1
13.9 1.38 (1.33-1.44) MI, Stroke, Organ
failure Infection 5.2 7.9 1.36 (1.30-1.40)
Pneumonia, Urinary tract, Sternal Septicemia 0.9 1
.4 Mortality or morbidity 10.4 15.5
(Carson et al JACC 2002 40202)
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PCI by diabetic state
Subgroup analysis pooled data (n 10
777) Endpoint death, MI or repeat
revascularisation
Clinical event ()
Diabetes Yes No
25 20 15 10 5 0
Trial Abizaid Elezi Carozza Marso Overall n
954 3554 5905 364 10777
(After Mak Faxon Europ Heart J 2003 241087)
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By pass surgery versus PCI
The BARI randomized trial comparing CABG and
PCI Patients with diabetes (n353)
Five year mortality by type of intervention
25 15 10 5 0
Adjusted RR 7.4 8.1
Mortality ()
CABG LIMA
CABG SVG
PCI
(The Bari Investigators Circulation 1997
961761)
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By pass surgery versus PCI
Stenting vs. CABG in multivessel disease Subgroup
analysis from ARTS Multivessel disease n 1 205
Diabetes n 208 (17)
Three year survival free from stroke, MI and
revascularization
100 90 80 70 60 50
Diabetes No Yes No Yes
CABG CABG
Eventfree survival ()
Stented PCI Stented PCI
0 240 480 720 960 1200
Follow up (days)
(Serruys et al Circulation 2004 1091114)
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By pass surgery versus PCI
CABG and PCI in the era of drug eluting stents
(Cypher) Patients with diabetes (n 518) Matched
pairs CABG (n 86) PCI (n 86)
Survival free from new interventions
Angina
CABG CYPHER
(Ben-Gal et al. Ann Thorac Surg 2006 822006)
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By pass surgery versus PCI
Drug eluting stents (sirolimus) Four years
survival in patients with diabetes (n 428)
HR 2.90 (95 CI 1.38-6.10) p0.008
Bare Metal Stents 96 Drug eluting
stents SIROLIMUS 88
Overall survival ()
(Spaulding et al New Engl J Med 2007 356989)
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Management of diabetes and glucose control
before, during and after PCI and CABG
Whenever possible, patients with diabetes should
be I C offered at least one and often
multiple arterial grafts
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Management of diabetes and glucose control
before, during and after PCI and CABG
Diabetes and coronary revascularization By pass
surgery versus PCI Adjunctive therapy
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Adjunctive therapy - Abciximab
Subgroup analysis of three RCT (EPIC, EPILOG,
EPISTENT) Pooled patients with (n 1 462) vs.
without diabetes (n 5 072)
One year survival
Diabetes placebo No diabetes Placebo
Diabetes ABX No diabetes ABX
Mortality ()
Follow up (days)
(Bhatt et al. JACC 2000 35922)
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Management of diabetes and glucose control
before, during and after PCI and CABG
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Management of diabetes and glucose control
before, during and after PCI and CABG
Diabetes and coronary revascularization By pass
surgery versus PCI Adjunctive therapy Revasculariz
ation in acute coronary syndromes
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Revascularization in acute coronary syndromes
Early revascularization in ACS comparing patients
with (n155) and without diabetes (n1 067) One
year event rate in FRISC II
OR 0.63 p 0.066
MI or Death ()
Death ()
30
30
25
25
20
20
OR 0.69 p NS
OR 0.72 p 0.018
15
15
OR 0.52 p 0.027
10
10
5
5
0
0
No diabetes
Diabetes
No diabetes
Diabetes
(Norhammar et al J Am Coll Card 2004 43 585)
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Revascularization in acute coronary syndromes
Early PCI vs. thrombolysis in diabetic patients
with AMI Fibrinolysis (n 99) or Primary PCI (n
103)
Survival free from death or reinfarction
100 80 60 40 20 0
Angioplasty Fibrinolysis
Cumulative survival ()
RR for PCI 0.29 (05 CI 0.15-0.57) plt0.001
Follow up (days)
(Hsu et al Heart 200288 268)
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Management of diabetes and glucose control
before, during and after PCI and CABG
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Management of diabetes and glucose control
before, during and after PCI and CABG
Diabetes and coronary revascularization By pass
surgery versus PCI Adjunctive therapy Revasculariz
ation in acute coronary syndromes Glucose control
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Revascularization in acute coronary syndromes
Mortality predictors in invasively managed
patients with ACS
RR 1.5 0.5 0.9 0.7 5.4 0.9 3.2 1.8 1.2 1.9
l
Age
l
Female gender
l
Angina
l
Hypertension
l
Diabetes
l
Smoking
l
Previous MI
l
ST depression
l
Troponin T gt0.03 µg/L
l
3-VD
n 1 222 Diabetes No 1 067 Yes 155
0.2
1
10
15
Relative risk (95 CI)
(Norhammar et al J Am Coll Card 2004 43 585)
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The importance of glucose control
Glycemia and mortality following PCI (n1
612) Glucometabolic classification via fasting
glucose
(Muhlestein et al. Am Heart J, 2003146 351)
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The importance of glucose control
Target vessel revascularization and
pre-procedural glycemia Patients with diabetes
(n162) Follow up 9 months
40 30 20 10 0
F-glucose
HbA1c
Revascularized ()
Quartile 1
2 3 4 B-glucose
mg/dl lt107 107-128 129-195
gt195
(Lindsay et al. Cardiovasc Revasc Med, 2007 815)
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Management of diabetes and glucose control
before, during and after PCI and CABG
Diabetes and coronary revascularization By pass
surgery versus PCI Adjunctive therapy Revasculariz
ation in acute coronary syndromes Glucose
control Unresolved issues
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Unresolved issues
On the amount and quality of presently available
information

• Limited
• Retrospective
• Therapy not updated
• Mostly subgroup-based
• Diabetes poorly described
• Glucose lowering therapy undefined

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Unresolved issues
On urgently needed information

• Trials dedicated to diabetic patients
• Accurately characterised patients
• Well defined concomitant therapy
• Carefully described glucose lowering drugs
• Mode of revascularization
• single vs. multivessel disease
• optimised technique
• The impact of tight glycemic control

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Unresolved issues
Important ongoing trials
FREEDOM Diabetes mellitus type 2 Randomised
to CABG or PCI (DES) Death, MI or repeat
revascularization Follow up 5 years
BARI IID Diabetes mellitus type 2
Revascularization or optimal medical therapy
Glucose lowering randomised Follow up 6 years
CARDia Diabetes mellitus type 2 CABG or PCI
modern techniques
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ESC/EASD Guidelines Diabetes, pre-diabetes and
cardiovascular disease
Management of cardiovascular risk acute coronary
syndromes