Cardiac Care in Diabetic Patients Haitham Amin Cardiologist MKCC Bahrain
CASE - Mrs A • 48 yr old • IFG for 5 years ( parents/siblings diabetic + CAD) • Now, Hga1c 8.5% and FBS 11 • Started on glucophage XR 1g OD • Came for cardiac evaluation • Asymptomatic ; inactive ; sheesha smoker • ECG----Normal • EXAM ----BP 140/80 ; BMI 33
LABS • • • • •
LDL 136 ( 3.6) TG 200 (2.3) HDL 40 (1.0) Normal RFT Normal LFT
Question 1 This patient requires an exercise stress test 1.Yes 2. No
Question 2 • Does this patient require Aspirin ? 1.Yes 2.No
Question 3 â&#x20AC;˘ What is the BP goal for this patient, and what is the first line anti-hypertensive of choice? 1.SBP < 120, ACEI inhibitor 2.SBP < 140, Beta-blocker 3.SBP < 140 , ACEI inhibitor 4.SBP <130 , HCTZ
Question 4 • Does this patient require statin, and if so, what is her LDL goal? • A. No statin • B. Statin yes. LDL goal < 2.6 mmol ( 100 mg%) • C. Statin yes. LDL goal < 1.7 mmol ( 70 mg%) • D. No statin. Consider fibrate for high TG.
Mrs A- Primary Prevention • • • •
Assess Global CVS Risk TLC Medications Stress – testing in asymptomatic patients
Calculation of Framingham Risk Score • • • • • • • • • •
15.9 % Obese SBP 140 mm Hg Uncontrolled T2DM High LDL High TG Low HDL Smoker Inactive Family History
CV Risk Factors
STANDARDS OF MEDICAL CARE IN DIABETES—2013
Cardiovascular Disease (CVD) in Individuals with Diabetes • CVD is the major cause of morbidity, mortality for those with diabetes • Common conditions coexisting with type 2 diabetes (e.g., hypertension, dyslipidemia) are clear risk factors for CVD • Diabetes itself confers independent risk • Benefits observed when individual cardiovascular risk factors are controlled to prevent/slow CVD in people with diabetes ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S28-29.
TLC Therapeutic Lifestyle Changes
Diet Medical Nutrition Therapy (MNT) â&#x20AC;˘ Individuals who have prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT (A)
ADA. V. Diabetes Care. Diabetes Care 2013;36(suppl 1):S22.
Recommendations: Physical Activity â&#x20AC;˘ Advise people with diabetes to perform at least 150 min/week of moderate-intensity aerobic physical activity (A)
â&#x20AC;˘ In absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week (A)
ADA. V. Diabetes Care. Diabetes Care 2013;36(suppl 1):S24.
Look AHEAD (Action for Health in Diabetes): Trial Halted Early • Intensive lifestyle intervention resulted in1 – Average 8.6% weight loss – Significant reduction of A1C – Reduction in several CVD risk factors
• Benefits sustained at 4 years2 • However, trial halted after 11 years of followup because there was no significant difference in primary cardiovascular outcome between weight loss, standard care group
1, 2. Look AHEAD Research Group. Diabetes Care. 2007;30:1374-1383 and Arch Intern Med. 2010;170:1566–1575; http://www.nih.gov/news/health/oct2012/niddk-19.htm.
Recommendations: Hypertension/Blood Pressure Control Goals â&#x20AC;˘ People with diabetes and hypertension should be treated to a systolic blood pressure goal of <140 mmHg (B) â&#x20AC;˘ Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
Recommendations: Hypertension/Blood Pressure Control Treatment (1) • Patients with a blood pressure (BP) >120/80 mmHg should be advised on lifestyle changes to reduce BP (B) • Patients with confirmed BP ≥140/80 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve BP goals (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
Recommendations: Hypertension/Blood Pressure Control Treatment (2)
• Lifestyle therapy for elevated BP (B) – Weight loss if overweight – DASH-style dietary pattern including reducing sodium, increasing potassium intake – Moderation of alcohol intake – Increased physical activity ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
Recommendations: Hypertension/Blood Pressure Control Treatment (3) • Pharmacological therapy (C) – A regimen that includes either an ACE inhibitor or angiotensin II receptor blocker; if one class is not tolerated, substitute the other
• Administer one or more antihypertensive medications at bedtime (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
Recommendations: Dyslipidemia/Lipid Management Treatment recommendations and goals • Statin therapy regardless of baseline lipid levels – with overt CVD (A) – without CVD >40 years of age who have one or more other CVD risk factors (A)
• For patients at lower risk (e.g., without overt CVD, <40 years of age) (C) – Consider statin therapy in addition to lifestyle therapy if LDL cholesterol remains >100 mg/dL – In those with multiple CVD risk factors
ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S31.
Recommendations: Dyslipidemia/Lipid Management Treatment recommendations and goals • In individuals without overt CVD – Primary goal is an LDL cholesterol <100 mg/dL (2.6 mmol/L) (B)
• In individuals with overt CVD – Lower LDL cholesterol goal of <70 mg/dL (1.8 mmol/L), using a high dose of a statin, is an option (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S31.
Recommendations: Dyslipidemia/Lipid Management (5) Treatment recommendations and goals (4) • If targets not reached on maximal tolerated statin therapy – Alternative therapeutic goal: reduce LDL cholesterol ~30–40% from baseline (B)
• Triglyceride levels <150 mg/dL (1.7 mmol/L), • HDL cholesterol >40 mg/dL (1.0 mmol/L) in men and >50 mg/dL (1.3 mmol/L) in women, are desirable (C) ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S31.
Recommendations: Glycemic, Blood Pressure, Lipid Control in Adults A1C
<7.0%*
Blood pressure
<140/80 mmHgâ&#x20AC;
Lipids: LDL cholesterol
<100 mg/dL (<2.6 mmol/L) < 70 mg /dl ( secondary prevention)
Statin therapy for those with history of MI or age >40+ or other risk factors
ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S33; Table 10.
Recommendations: Antiplatelet Agents (1) • Consider aspirin therapy (75–162 mg/day) (C) – As a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk >10%) – Includes most men >50 years of age or women >60 years of age who have at least one additional major risk factor • • • • •
Family history of CVD Hypertension Smoking Dyslipidemia Albuminuria
ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S32-S33.
Recommendations: Antiplatelet Agents (2) • Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk. • 10-year CVD risk <5%: men <50 and women <60 years of age with no major additional CVD risk factors
• In patients in these age groups with multiple other risk factors (10-year risk 5–10%), clinical judgment is required (E)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S33.
Recommendations: Antiplatelet Agents (3) • Use aspirin therapy (75–162 mg/day) – Secondary prevention strategy in those with diabetes with a history of CVD (A)
• For patients with CVD and documented aspirin allergy – Clopidogrel (75 mg/day) should be used (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S33-S34.
Recommendations: Smoking Cessation â&#x20AC;˘ Advise all patients not to smoke or use tobacco products (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S34.
Recommendations: Coronary Heart Disease Screening â&#x20AC;˘ In asymptomatic patients, routine screening for CAD is not recommended, as it does not improve outcomes as long as CVD risk factors are treated (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S34.
Your dose of diabetes
The Baskin Robbins Large Heath Bar Shake 2310 calories three dayâ&#x20AC;&#x2122;s worth of recommended daily allowance of fat.
CASE- Mrs F • • • • • • •
51 yr old woman Poorly Controlled Diabetic 10 yrs (Hga1c 9%) Obese Dyslipidemic Presented with Unstable Angina ECG : gross ST depression (inferolateral) Referred for coronary angiography
Cath: Left Main and RCA stenosis
Question 1 • For diabetic patients with significant Left main and 3 vessel CAD, the best option is: • • • •
A. CABG B. Angioplasty / stenting C. No difference between A and B D. Depends on patient wishes and local expertise.
Question 2 • For diabetics with established CAD, LDL goal is • • • •
A. < 2.6 mmol/l ( 100 mg %) B < 1.8 mmol/l ( 70 mg%) C. < 3.0 mmol/l (114 mg%) D. No target as long as patient is on statin
Question 3 • Diabetics undergoing CABG or angioplasty /stenting have more complications and worse outcomes(prognosis) that non-diabetics. • A. Yes • B. No
Cath: Left Main and RCA stenosis Refused CABG
• Had DES Stent to RCA and Left main • Medications: – Insulin /OHA – Aspirin + clopidogrel – Betablockers – ACEI inhibitors – Statin
MORTALITY FROM CAD IN TYPE 2 DM & IN NONDIABETICS WITH & WITHOUT PRIOR MI ,Haffner et al, NEJM 1998 ; 339: 229-34
• 7 yr follow-up of > 1000 DM / Non-DM • Both groups with / without CAD • Endpoints : MI , Stroke , Death
INCIDENCE OF MI 45 40 35 30 25
nondiabetic diabetic
20 15 10 5 0
NO CAD
CAD
INCIDENCE OF STROKE 20 18 16 14 12 Nondiabetics Diabetics
10 8 6 4 2 0
NO CAD
CAD
CVD MORTALITY 45 40 35 30 25
Nondiabetics Diabetics
20 15 10 5 0
NO CAD
CAD
Conclusion Diabetics without CAD have similar events ( MI, Stroke) and Mortality as Nondiabetics with established CAD. Diabetics = Non-diabetic + prior MI. Diabetics with CAD do poorly.
Diabetics at Higher CVD Risk • • • • •
2-8 fold increase CVD risk 2/3 Mortality ¾ of hospital admissions Do worse after acute MI Risk across the sugar spectrum ( IFGIGT-T2DM)
The Unifying Hypothesis of Diabetic Vascular Disease “Common-Soil Hypothesis”
Laakso 2008
Recommendations: Coronary Heart Disease Treatment (1) • To reduce risk of cardiovascular events in patients with known CVD, consider – ACE inhibitor (C) – Aspirin* (A) – Statin therapy* (A)
• In patients with a prior MI – β-blockers should be continued for at least 2 years after the event (B)
*If not contraindicated. ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S34.
160 Patients randomized Add ACEI, aspirin, statins to strict targets T2DMvs+standard microalbuminuria treatment Gaede NEJM 2008
Strong Treatment Effect Number needed to treat (NNT) for 13 years to avoid one Death Cardiovascular death Major CV event Nephropathy
5 8 3 5
Gaede NEJM 2008
All T2DM patients should receive 1. Aspirin 2. Statin 3. ACEI â&#x20AC;&#x201C;ARBs 4. Hga1c <7% 5. BP < 140/80 6. Exercise
Triple Protection
Revascularization in Diabetics; PCI vs CABG
EDUCATIONAL CONTENT ENDORSED BY EAPCI,
A REGISTERED BRANCH OF THE EUROPEAN SOCIETY OF CARDIOLOGY
AHA 2012 © 2013 Europa Edition. All rights reserved.
Table 7
FREEDOM Trial Main Results AHA 2012 November 4, 2012 Los Angeles, CA Valentin Fuster, MD PhD
FREEDOM Design Eligibility: Eligibility: DM DM patients patients with with MV-CAD MV-CAD eligible eligible for for stent stent or or surgery surgery Exclude: Exclude: Patients Patients with with acute acute STEMI STEMI
Randomized 1:1
MV-Stenting MV-Stenting With With Drug-eluting Drug-eluting
CABG CABG With With or or Without Without CPB CPB
All concomitant Meds shown to be beneficial were encouraged, including: clopidogrel, ACE inhib., ARBs, b-blockers, statins
PRIMARY OUTCOME – DEATH / STROKE / MI PCI/DES CABG Logrank P=0.005
Death/Stroke/MI, %
30
PCI/DES
20
CABG 10
5-Year Event Rates: 26.6% vs. 18.7%
0 0
1
2
3
4
5
6
Years post-randomization PCI/DES N 953
848
788
625
416
219
40
CABG N 943
814
758
613
422
221
44
Myocardial Infarction, %
MYOCARDIAL INFARCTION PCI/DES CABG
30
Logrank P<0.0001 20
13.9 % PCI/DES
6.0%
10
CABG 0
0
1
2
3
4
5
Years post-randomization
PCI/DES N 953
853
798
636
422
220
CABG N 947
824
772
629
432
229
All-Cause Mortality, %
ALL-CAUSE MORTALITY PCI/DES CABG
30
Logrank P=0.049
20
PCI/DES
10
CABG 5-Year Event Rates: 16.3% vs. 10.9%
0
0
1
2
3
4
5
466 449
243 238
Years post-randomization PCI/DES N 953 CABG N 947
897 855
845 806
685 655
Conclusion â&#x20AC;˘ In patients with diabetes and advanced coronary disease, CABG was of significant benefit as compared to PCI. MI & all cause mortality were independently decreased, while stroke was slightly increased â&#x20AC;˘ CABG surgery is the preferred method of revascularization for patients with diabetes & multi-vessel CAD.
Thank You