1、,10th South China International Congress of Cardiology ACE trial symposiumPrognostic 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 fromhttp:/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,GAMI1n=164,34%,35%,31%,(1. Norhammar et al. La
3、ncet. 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, Ryd
4、n 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/L),
5、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 imaginedNewly detected dysglycemia relates to impaired prognosis,Implications of the Europe
6、an and China Heart Surveys,RR 1995-1998 =1.42 RR 1999-2002 =1.31,1995 1996 1997 1998 1999 2000 2001 2002,Year,Mortality (%),3020100,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 the Sw
7、edish 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 - major
8、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),0.92,No
9、rmal,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 imaginedNewly detected dysglycemia relates to impaired prog
10、nosisA 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),(Stamler et al Di
11、abetes 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 modificationfat 30% (satur 10%)exercise 30 min x3-5/weeksmoking ces
12、s courses Vitamin supplementation Stepwise introduced drugs Hypoglycemic regimenaccording to strict rules,By their GP Guidelines by Danish Med Ass 1998 & 2000 Referral if neededn = 53 (average 3 times/pat),Intensive treatment,Conventional treatment,Multifactorial intervention in type 2 diabetes The
13、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 New Engl Med 20
14、03; 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,Conventional,Intensive,E
15、xtendend study protocol,(Gaede et al New Engl J Med 2008; 358: 580 ),Impact of intensive therapy on OR 95% CI ARR p-valueAll-cause mortality 0.54 0.32-0.89 20% 0.015Cardiovascular mortality 0.43 0.19-0.94 13% 0.036Major cardiovascular events 0.41 0.25-0.63 29% 0.001,Multifactorial intervention in ty
16、pe 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 statins if not contra
17、indicated,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 diabetes and the he
18、art 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,0,82,0,86,0,90,0,94,0,98,1,00,p0.
19、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 of Revascularisat
20、ion 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,Euro Heart Survey
21、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,Treatment type Diabetes NN
22、T to avoid one eventFatal 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 disease than imaginedNewl
23、y detected dysglycemia relates to impaired prognosisA multifactorial risk factor management importantGlucose controlIn patients with established diabetesIn patients with newly detected glycemic perturbations,with CAD,(Stettler C et al. Am Heart J 2006; 152: 27),Peripheral,Cardiac,Cerebrovascular,Any
24、 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 with acarbose,(Chiasson, J.
25、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 unknown,285*,736*,1819 OGTT
26、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 glucose lowering drugs 77
27、 (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),0,90,0,92,0,94,0,96,0,98,1,00,Log
28、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 Heart Survey diabetes a
29、nd 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 evidence-based treatmen
30、ts,(Anselmino et al; Europ Heart J 2008; 29:177),Guideline recommendations,Recommendation Class LevelImproved control of post-prandial glycemia may IIb C lower CV risk and mortality,Need for further researchAvailable data promising,10th South China International Congress of Cardiology ACE trial symposiumPrognostic and potential therapeutic implications of the European and China Heart surveys,Time for questions,
