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1、,10th South China International Congress of Cardiology ACE trial symposium Prognostic and potential therapeutic implications of the European and China Heart surveys,Lars Rydn Karolinska Institutet Stockholm, Sweden,Implications of the European and China Heart Surveys,European Guidelines on Diabetes,
2、 prediabetes and Cardiovascular Disease may be downloaded from http:/www.escardio.org http:/www.easd.org,Implications of the European and China Heart Surveys,Diabetes and prediabetes is more common among patients with coronary artery disease than imagined,GAMI1 n=164,34%,35%,31%,(1. Norhammar et al.
3、 Lancet. 2002;359:21404),Dysglycemia and coronary artery disease Glucometabolic category by OGTT in patients without known perturbations,DM,IGT,IFG,Normal,OGTT,OGTT,FPGWHO,FPGADA,0,20,40,60,80,100,%,WHO 1999 criterion (FPG 6.1 mmol/l),ADA 2003 criterion (FPG 5.6 mmol/l),% of all with OGTT,(Bartnik,
4、Rydn et al Heart 2007; 93:72),Dysglycemia and coronary artery disease Classification according to FPG or OGTT,Mortality in CVD Relation to fasting and postprandial glycemia in patients without diabetes,0,0.5,1,1.5,2,2.5,6.1,6.1- 6.9,7.0- 7.7,7.8,7.8,7.8-11.0,11.1,Fasting glucose (mmol/L),OGTT (mmol/
5、L),Relative risk,Adjusted for age, gender and area,(The DECODE study group Lancet 1999; 354:617),Guideline recommendations,Diabetes and prediabetes is more common among patients with coronary artery disease than imagined Newly detected dysglycemia relates to impaired prognosis,Implications of the Eu
6、ropean and China Heart Surveys,RR 1995-1998 =1.42 RR 1999-2002 =1.31,1995 1996 1997 1998 1999 2000 2001 2002,Year,Mortality (%),30 20 10 0,No,Yes,The Swedish CCU registry 1995 - 2002,Time trends in 1-year mortality in patients with AMI ),Patients with (n= 14 873) and without (n=50 009) diabetes From
7、 the Swedish National Registry for MI,Diabetes,(Norhammar et al Heart J 2007; 93:1577 ),OGTT at discharge (n= 168),Abnormal 67%,Follow-up time (months),0,Normal,Abnormal,Probability of event free survival,two-sided p = 0.002,10,20,30,40,50,Time to Major Cardiovascular Event,0.0,0.8,0.7,1.0,0.9,GAMI
8、- major cardiovascular events,(Bartnik et al Europ Heart J 2004; 25:1990),Glucometabolic state,Euro Heart Survey diabetes and the heart Survival in relation to glucometabolic state,(Lentzen et al Europ Heart J 2006; 27:2969),Known DM,New DM,1.00,0.94,0.96,0.98,0,100,200,400,300,Follow up time (days)
9、,0.92,Normal,IGT,Log rank test p 0.001,Survival probability,Glucometabolic state,Guideline recommendations,Implications of the European and China Heart Surveys,Diabetes and prediabetes is more common among patients with coronary artery disease than imagined Newly detected dysglycemia relates to impa
10、ired prognosis A multifactorial risk factor management important,Dysglycemia and cardiovascular risk a continuum,80,60,40,30,10,5,80,60,40,30,10,5,Systolic blood pressure (mm Hg),Serum cholesterol (mmol/L),No diabetes,Diabetes,110,120,130,140,150,160,4,5,6,7,Ten-year CHD mortality (per 1000),(Stamle
11、r et al Diabetes Care 1993; 16:434),Multifactorial intervention in type 2 diabetes The Steno 2 study - 8 year follow up,(Gaede et al New Engl Med 2003; 348:383),Study protocol,Project team every 3 months Strict therapeutic targets Behavioural modification fat 30% (satur 10%) exercise 30 min x3-5/wee
12、k smoking cess courses Vitamin supplementation Stepwise introduced drugs Hypoglycemic regimen according to strict rules,By their GP Guidelines by Danish Med Ass 1998 & 2000 Referral if needed n = 53 (average 3 times/pat),Intensive treatment,Conventional treatment,Multifactorial intervention in type
13、2 diabetes The Steno 2 study 8 year follow up,(Gaede et al New Engl Med 2003; 348:383),Management principles,Multifactorial intervention in type 2 diabetes The Steno 2 study 8 years of follow up,Composite endpoint CV-death, MI or stroke, CABG or PCI, limb amputation or vascular surgery,(Gaede et al
14、New Engl Med 2003; 348:383),Microvascular,Mortality,4 years,13 years,n=80,n=80,n=160,Microvascular,Mortality,4 years,13 years,Macrovascular,8 years,Macrovascular,8 years,Primary endpoint,1993,1997,2001,2006,Multifactorial intervention in type 2 diabetes The Steno 2 study 13 years follow up,Conventio
15、nal,Intensive,Extendend study protocol,(Gaede et al New Engl J Med 2008; 358: 580 ),Impact of intensive therapy on OR 95% CI ARR p-value All-cause mortality 0.54 0.32-0.89 20% 0.015 Cardiovascular mortality 0.43 0.19-0.94 13% 0.036 Major cardiovascular events 0.41 0.25-0.63 29% 0.001,Multifactorial
16、intervention in type 2 diabetes The Steno 2 study 13 year follow up,(Gaede et al New Engl J Med 2008; 358: 580 ),Euro Heart Survey diabetes and the heart Impact of Evidence Based Medicine on 1-year prognosis,Evidence based medicine The combined use of -blockade, RAA-inhibition, antiplatelets and sta
17、tins if not contraindicated,Revascularization thrombolysis, PCI or CABG during index hospitalisation,(Anselmino et al Europ J Cardiovasc Prev Rehab 2008; In press),p0.001,0,100,200,300,400,0,91,0,92,0,93,0,94,0,95,0,96,0,97,0,98,0,99,1,00,No DM EBM +,No DM EBM -,DM EBM +,DM EBM -,Euro Heart Survey d
18、iabetes and the heart Impact of Evidence Based Medicine (EBM) on 1-year mortality,Time of follow up (days),Cumulative survival,(Anselmino et al Europ J Cardiovasc Prev Rehab 2008; In press),Euro Heart Survey diabetes and the heart Impact of Evidence Based Medicine (EBM) on 1-year CVE,0,82,0,86,0,90,
19、0,94,0,98,1,00,p0.001,0,100,200,300,400,No DM EBM +,No DM EBM -,DM EBM +,DM EBM -,Time of follow up (days),Cumulative survival,(Anselmino et al Europ J Cardiovasc Prev Rehab 2008; In press),p0.001,0,100,200,300,400,DM RV +,DM RV -,No DM RV +,No DM RV -,Euro Heart Survey diabetes and the heart Impact
20、 of Revascularisation on 1-year mortality,Cumulative event free rate,Time of follow up (days),(Anselmino et al Europ J Cardiovasc Prev Rehab 2008; In press),p0.001,0,80,0,82,0,84,0,86,0,88,0,90,0,92,0,94,0,96,1,00,Time of follow up (days),0,100,200,300,400,No DM RV +,No DM RV -,DM RV +,DM RV -,1,00,
21、Euro Heart Survey diabetes and the heart Impact of Revascularisation on 1-year cardiovascular events,Cumulative event free rate,(Anselmino et al Europ J Cardiovasc Prev Rehab 2008; In press),Euro Heart Survey diabetes and the heart Number needed to treat (NNT) with EBM and Revascularisation,Treatmen
22、t type Diabetes NNT to avoid one event Fatal Cardiovascular,(Anselmino et al Europ J Cardiovasc Prev Rehab 2008; In press),Guideline recommendations,Variable Target,Implications of the European and China Heart Surveys,Diabetes and prediabetes is more common among patients with coronary artery diseas
23、e than imagined Newly detected dysglycemia relates to impaired prognosis A multifactorial risk factor management important Glucose control In patients with established diabetes In patients with newly detected glycemic perturbations,with CAD,(Stettler C et al. Am Heart J 2006; 152: 27),Peripheral,Car
24、diac,Cerebrovascular,Any macrovascular,Incidence Rate Ratio,Glycemic control Evidence for impact on cardiovascular events,Glycemic control Evidence for impact on cardiovascular events,The STOP NIDDM trial, testing the possibility to prevent progression from impaired glucose tolerance to diabetes wit
25、h acarbose,(Chiasson, J.L. et al. JAMA 2003; 290: 486),Glycemic control Incidence of composite cardiovascular events in the STOP-NIDDM trial,(Chiasson, J.L. et al. JAMA 2003; 290: 486),4961,4676,3940,Enrolled,Lost to follow-up,Study population,Glucometabolic state available,Glucometabolic state unkn
26、own,285*,736*,1819 OGTT 696 FPG,947 Normal glucose regulation,1116 Impaired glucose regulation,1425 Known diabetes,452 Newly detected diabetes,452 Newly detected diabetes,Glycemic control Experiences from the Euro Heart Survey Study population,(Lentzen et al Europ Heart J 2006; 27:2969),Prescribed g
27、lucose lowering drugs 77 (17%),Newly detected diabetes n = 452,Not prescribed glucose lowering drugs 375 (83%),Glycemic control Experiences from the Euro Heart Survey Glucose lowering drugs at follow up in patients with newly detected diabetes,(Anselmino et al; Europ Heart J 2008; 29:177),0,90,0,92,
28、0,94,0,96,0,98,1,00,Log rank test p=0.047,Yes,No,0,100,200,300,400,Cumulative event free rate,Time of follow up (days),Glucose lowering drug,Euro Heart Survey diabetes and the heart Impact of glucose lowering drugs on 1-year CV-events (Kaplan-Meier),(Anselmino et al; Europ Heart J 2008; 29:177),Euro
29、 Heart Survey diabetes and the heart HR for the impact of GLD on 1-year CV events in newly detected DM,0.041,(0.05-0.97),0.22,0.043,(0.02-0.97),0.13,p,(95%CI),HR,0.5 1.0 1.5,All-cause mortality/MI,CV mortality, MI or stroke,Variable,Adjusted for age, sex, previous cardio-vascular diseases and use of
30、 evidence-based treatments,(Anselmino et al; Europ Heart J 2008; 29:177),Guideline recommendations,Recommendation Class Level Improved control of post-prandial glycemia may IIb C lower CV risk and mortality,Need for further research Available data promising,10th South China International Congress of Cardiology ACE trial symposium Prognostic and potential therapeutic implications of the European and China Heart surveys,Time for questions,