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Revascularization vs Medical Treatment for Coronary Disease in Diabetes

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Lecture given at the 2010 Diabetes Philippines annual convention

Lecture given at the 2010 Diabetes Philippines annual convention

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  • 1. Revascularization vs Medical Treatment for Coronary Disease in Diabetes Iris Thiele Isip Tan MD, FPCP, FPSEM Clinical Associate Professor, UP College of Medicine Section of Endocrinology, Diabetes & Metabolism Department of Medicine, Philippine General Hospital
  • 2. Disclosure I’m not a cardiologist :) “Heads, you get a quadruple bypass. Tails, you take a baby aspirin.”
  • 3. When does CABG offer benefits over PCI? When can revascularization be offered to patients on medical therapy? Who should be screened for CAD?
  • 4. Who should be screened for CAD? Silent myocardial infarction (SMI) is more frequent in diabetes Which asymptomatic diabetic should be screened? Which is the more appropriate non-invasive test to determine the presence of CAD? CAD accounts for >75% of deaths in diabetes
  • 5. Screening for CAD in diabetes Other atherosclerotic vascular disease Microalbuminuria and chronic kidney disease Abnormal resting ECG Autonomic neuropathy Retinopathy Hyperglycemia Age & sex Unexplained dyspnea Multiple cardiac risk factors ADA (2007) Bax et al Diabetes Care 2007;30:2729-36
  • 6. Exercise ECG to screen high-risk patients Ischemia imaging as initial strategy only in patients with abnormal resting ECGs ADA (1998) Bax et al Diabetes Care 2007;30:2729-36
  • 7. Cardiac CT* using electron beam or multislice technology If medical goals cannot be met Those with strong clinical suspicion of very-high-risk CAD Bax et al Diabetes Care 2007;30:2729-36 ADA (2007) * AHA Class IIB recommendation for intermediate risk
  • 8. Further testing if coronary calcium score >400 considering age and renal function Bax et al Diabetes Care 2007;30:2729-36 Calcium score 1-10 minimal CAD 11-100 mild 101-400 moderate >400 extensive ADA (2007)
  • 9. First CHD events and stroke Median follow-up: 4 years Coronary artery calcium score (CACS) + risk factors (lipoprotein, apolipoprotein, homocysteine, CRP, HOMA-IR, UAC ratio) 589 T2DM with no history of CVD O: I: P: PREDICT RCT Elkeles et al Eu Heart J 2008;29:2244-51
  • 10. e 2 Primary endpoint event rates in successive categories of coronary artery calcification score. Each unit increase in log2 (CACSþ1) ents a doubling in CACS. The calcification score categories 0–10, 11–100, 101–400, 401–1000, and 1001–10000 include log- rmed CACS categories 1–4, 4–7, 7–9, 9–10, and 11, respectively. Dotted lines show 95% confidence intervals. DICT study 224CACS Independent Predictor of CHD/stroke 66 CV events (10 strokes) Elkeles et al Eu Heart J 2008;29:2244-51 Doubling of CACS = 29% risk PREDICT
  • 11. Further testing if coronary calcium score >400 considering age and renal function SPECT: myocardial perfusion Stress echocardiography: ischemic wall motion abnormalities Bax et al Diabetes Care 2007;30:2729-36 ADA (2007)
  • 12. Cardiac death or nonfatal MI No screening vs adenosine-stress radionuclide myocardial perfusion imaging (MPI) 1123 T2DM and no symptoms of CAD O: I: P: DIAD Young LH et al JAMA 2009;301(15):1547-55 RCT
  • 13. Young LH et al JAMA 2009;301(15):1547-55 DIAD HR 0.88; 95%CI (0.44,1.80) p=0.73 15 events 17 events Cumulative Incidence of Cardiac Events Low event rate 2.9% over 5 y (0.6%/yr)
  • 14. NPV normal MPI 98% PPV Any abnormality 6% Mod/large defects 12% Cumulative Incidence of Cardiac Events by Screening Group Young LH et al JAMA 2009;301(15):1547-55
  • 15. Routine screening for inducible ischemia in asymptomatic T2DM not advocated Low yield of detecting significant inducible ischemia Low overall cardiac event rate Routine screening does not appear to affect overall outcome Prohibitively expensive Young LH et al JAMA 2009;301(15):1547-55
  • 16. Further testing if coronary calcium score >400 considering age and renal function SPECT: myocardial perfusion Stress echocardiography: ischemic wall motion abnormalities Bax et al Diabetes Care 2007;30:2729-36 Stress echo? ADA (2007)
  • 17. Non-fatal MI, late myocardial revascularization and cardiac death Symptom-limited treadmill exercise testing (Bruce protocol) + 2-D echo at rest and immediately after exercise 193 T2DM with suspected or known CAD referred for EE O: I: Prognostic Value of Exercise Echo (EE) P: Oliveira JLM et al Cardiovascular Ultrasound 2009;7:24 Retrospective
  • 18. Oliveira JLM et al Cardiovascular Ultrasound 2009;7:24 Survival Free of Cardiac Events Kaplan-Meier curves Normal Abnormal RR 3.63, 95%CI (1.09-6.02) p=0.03 Cardiac events + EE 20.6% - EE 7%
  • 19. Serial testing? Low cardiac event rate within 2 years after normal stress myocardial perfusion or echo studies Bax et al Diabetes Care 2007;30:2729-36 progressive atherosclerosis Warranty
  • 20. Suspect CAD Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 21. Suspect CAD Asymptomatic Selective ischemia assessment Myocardial perfusion imaging Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 22. Suspect CAD Mild to moderate symptoms CCS Class I, II Normal or single segment abnormal OMT Asymptomatic Selective ischemia assessment Myocardial perfusion imaging Optimal medical therapy BP <130/80 LDL <70 HbA1c <7% Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 23. Suspect CAD Mild to moderate symptoms CCS Class I, II Normal or single segment abnormal Multisegmental abnormalities OMT Coronary angiography Asymptomatic Selective ischemia assessment Myocardial perfusion imaging Optimal medical therapy BP <130/80 LDL <70 HbA1c <7% Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 24. Suspect CAD Mild to moderate symptoms CCS Class I, II Significant symptoms CCS Class III, IV Normal or single segment abnormal Multisegmental abnormalities OMT Coronary angiography Asymptomatic Selective ischemia assessment Myocardial perfusion imaging Optimal medical therapy BP <130/80 LDL <70 HbA1c <7% Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 25. When does CABG offer benefits over PCI? When can revascularization be offered to patients on medical therapy? Who should be screened for CAD?
  • 26. Primary - all-cause mortality Secondary - composite of death, MI or stroke Prompt revascularization with intensive medical therapy vs intensive medical therapy alone 2368 T2DM with heart disease BARI 2D O: I: P: RCT BARI 2D Study Group. NEJM 2009;11:360(24):2503-15
  • 27. Hypothesis Prompt revascularization would reduce long- term rates of death and CV events, as compared with medical therapy alone. BARI 2D Study Group. NEJM 2009;11:360(24):2503-15
  • 28. BARI 2D Study Group. NEJM 2009;11:360(24):2503-15 Medical therapy Insulin- sensitization Medical therapy Insulin-provision therapy Prompt revascularization Insulin-provision therapy Prompt revascularization Insulin- sensitization CABG PCI Stratified randomization facto"al 2 x 2
  • 29. Prompt revascularization Undergo procedure within 4 weeks after randomization Stratified randomization: PCI or CABG BARI 2D Study Group. NEJM 2009;360(24):2503-15
  • 30. Medical therapy for all patients HbA1c <7% LDL <100 mg/dL BP <130/80 mm Hg Counseling on smoking cessation, weight loss and regular exercise Feedback on risk factor control Follow-up monthly for first 6 months then q3 months thereafter BARI 2D Study Group. NEJM 2009;360(24):2503-15
  • 31. BARI 2D Study Group. NEJM 2009;360(24):2503-15
  • 32. BARI 2D Study Group. NEJM 2009;360(24):2503-15
  • 33. BARI 2D Study Group. NEJM 2009;360(24):2503-15 Non-fatal MI Revascularization grp 7.4% Medical therapy 14.6%
  • 34. Myocardial Jeopardy Index (MJI) percentage of myocardial segments supplied by significantly diseased coronary arteries or their branches
  • 35. Coronary angiography Fuster V & Farkouh ME. Circulation 2010;121:2540-52 Mild to moderate symptoms CCS Class I, II Significant symptoms CCS Class III, IV MJI = Myocardial Jeopardy Index
  • 36. Coronary angiography Fuster V & Farkouh ME. Circulation 2010;121:2540-52 Normal or non-obstructive Mild to moderate symptoms CCS Class I, II Significant symptoms CCS Class III, IV OMT Optimal medical therapy BP <130/80 LDL <70 HbA1c <7% MJI = Myocardial Jeopardy Index
  • 37. Coronary angiography Fuster V & Farkouh ME. Circulation 2010;121:2540-52 Normal or non-obstructive Mild to moderate symptoms CCS Class I, II Significant symptoms CCS Class III, IV Non- obstructive OMT Optimal medical therapy BP <130/80 LDL <70 HbA1c <7% MJI = Myocardial Jeopardy Index
  • 38. Coronary angiography Fuster V & Farkouh ME. Circulation 2010;121:2540-52 Normal or non-obstructive Mild to moderate symptoms CCS Class I, II Significant symptoms CCS Class III, IV Obstructive AND low MJI Deferred revascularization + OMT Non- obstructive OMT Optimal medical therapy BP <130/80 LDL <70 HbA1c <7% MJI = Myocardial Jeopardy Index
  • 39. Coronary angiography Fuster V & Farkouh ME. Circulation 2010;121:2540-52 Normal or non-obstructive Mild to moderate symptoms CCS Class I, II Significant symptoms CCS Class III, IV Obstructive AND low MJI Obstructive AND high MJI Deferred revascularization + OMT Prompt revascularization + OMT Obstructive Non- obstructive OMT Optimal medical therapy BP <130/80 LDL <70 HbA1c <7% MJI = Myocardial Jeopardy Index
  • 40. When does CABG offer benefits over PCI? When can revascularization be offered to patients on medical therapy? Who should be screened for CAD?
  • 41. Tempting but incorrect to conclude from BARI 2D ... for type 2 DM with severe angiographic CAD, CABG is better than PCI Rutter MK & Nesto RW. Heart 2010;96:1436-40
  • 42. Rutter MK & Nesto RW. Heart 2010;96:1436-40 Evidence-based appropriate therapy for CAD in diabetes by symptom and/or disease severity
  • 43. original BARI study Diabetes subgroup CABG with significantly better 5-year (80% vs 67%) and 10-year (58% vs 46%, p=0.025) survival when compared to balloon PCI CABG vs PCI 1829 patients (most had unstable angina and multivessel disease) O: I: P: BARI Investigators. NEJM 1996;335:217-25 RCT
  • 44. Coronary Artery Revascularization in Diabetes (CARDia) Underpowered to compare individual outcomes Composite (death, stroke or MI) similar for CABG and PCI-treated (10.5% vs 13%, p=0.39); More repeat procedures with PCI CABG or PCI with abciximab and stenting 510 diabetics with multivessel or complex single-vessel CAD O: I: P: RCT Kapur A et al. J Am Coll Cardiol 2010;55:432-40
  • 45. SYNergy between PCI with TAXus and cardiac surgery (SYNTAX) More major cardiac and cerebrovascular events with PCI (26% vs 14%, p=0.003) PCI mortality higher for highly complex lesions (13.5% vs 4.1%, p=0.003) CABG vs PCI (paclitaxel-eluting stents) Post hoc data for those with diabetes 1800 patients with complex left main or three-vessel disease (452 with diabetes) O: I: P: RCT one-year data Banning AP et al. J Am Coll Cardiol 2010;55:1067-75
  • 46. Future REvascularization Evaluation in Patients with Diabetes: Optimal Management of Multivessel Disease (FREEDOM) Total and CVD mortality at 1-5 years Quality of life and cost-effectiveness CABG vs DES stent PCI in the setting of optimal medical therapy ~2058 patients with diabetes and multivessel disease O: I: P: Farkouh et al. Am Heart J 2008;155:215-23 RCT
  • 47. JNJhealth “Coronary Stent Animation” 3 Sept 2008, http://www.youtube.com/watch?v=9FPapBbbS4o&feature=channel. Accessed 25 Oct 2010 Coronary grafts bypass proximal segments of vessels taking many atheromatous lesions out of play Stents leave behind substantial coronary plaque
  • 48. Summary Type 2 diabetes CABG best for multivessel CAD and/or LV systolic dysfunction PCI with DES is equivalent to CABG in single-vessel disease and normal LV systolic function Page BJ et al. Curr Diab Rep 2010;10:10-15
  • 49. When does CABG offer benefits over PCI? When can revascularization be offered to patients on medical therapy? Who should be screened for CAD?
  • 50. #ank Y$ http://www.endocrine-witch.net