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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. “Heads, you get a quadruple bypass. Tails, you take a baby aspirin.” Disclosure I’m not a cardiologist :)
  • 3. Who should be screened for CAD? When can revascularization be offered to patients on medical therapy? When does CABG offer benefits over PCI?
  • 4. Who should be Silent myocardial screened for CAD? infarction (SMI) is more frequent in diabetes Which asymptomatic diabetic should be screened? CAD accounts for >75% of deaths in diabetes Which is the more appropriate non-invasive test to determine the presence of CAD?
  • 5. ADA (2007) Other atherosclerotic Screening for vascular disease CAD in diabetes Microalbuminuria and chronic kidney disease Abnormal resting ECG Autonomic neuropathy Retinopathy Hyperglycemia Age & sex Unexplained dyspnea Multiple cardiac risk factors Bax et al Diabetes Care 2007;30:2729-36
  • 6. ADA (1998) Exercise ECG to screen high-risk patients Ischemia imaging as initial strategy only in patients with abnormal resting ECGs Bax et al Diabetes Care 2007;30:2729-36
  • 7. ADA (2007) Cardiac CT* using electron beam or multislice technology If medical goals cannot be met Those with strong clinical suspicion of very-high-risk CAD * AHA Class IIB recommendation for intermediate risk Bax et al Diabetes Care 2007;30:2729-36
  • 8. Calcium score 1-10 minimal CAD 11-100 mild 101-400 moderate >400 extensive ADA (2007) Further testing if coronary calcium score >400 considering age and renal function Bax et al Diabetes Care 2007;30:2729-36
  • 9. P: PREDICT 589 T2DM with no history of CVD I: Coronary artery calcium score (CACS) + risk factors (lipoprotein, apolipoprotein, homocysteine, CRP, HOMA-IR, UAC ratio) O: First CHD events and stroke Median follow-up: 4 years RCT Elkeles et al Eu Heart J 2008;29:2244-51
  • 10. PREDICT DICT study CACS 224 Independent Predictor of CHD/stroke Doubling of CACS = 29% risk e 2 Primary endpoint event rates in successive categories of coronary artery calcification score. Each unitstrokes) log2 (CACSþ1) 66 CV events (10 increase in 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 Elkeles et al95% Heart J 2008;29:2244-51 lines show Eu confidence intervals.
  • 11. ADA (2007) 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
  • 12. P: DIAD 1123 T2DM and no symptoms of CAD I: No screening vs adenosine-stress radionuclide myocardial perfusion imaging (MPI) O: Cardiac death or nonfatal MI RCT Young LH et al JAMA 2009;301(15):1547-55
  • 13. DIAD Cumulative Incidence of Cardiac Events Low event rate 2.9% over 5 y (0.6%/yr) HR 0.88; 95%CI (0.44,1.80) p=0.73 17 events 15 events Young LH et al JAMA 2009;301(15):1547-55
  • 14. Cumulative Incidence of Cardiac Events by Screening Group NPV normal MPI 98% PPV Any abnormality 6% Mod/large defects 12% Young LH et al JAMA 2009;301(15):1547-55
  • 15. Low yield of detecting significant inducible ischemia Low overall cardiac event rate Routine screening does not appear to affect overall outcome Prohibitively expensive Routine screening for inducible ischemia in asymptomatic T2DM not advocated Young LH et al JAMA 2009;301(15):1547-55
  • 16. ADA (2007) Further testing if coronary calcium score >400 considering age and renal function SPECT: myocardial perfusion Stress echocardiography: ischemic wall motion Stress echo? abnormalities Bax et al Diabetes Care 2007;30:2729-36
  • 17. Prognostic Value of Exercise Echo (EE) P: 193 T2DM with suspected or known CAD referred for EE I: Symptom-limited treadmill exercise testing (Bruce protocol) + 2-D echo at rest and immediately after exercise O: Non-fatal MI, late myocardial revascularization and cardiac death Retrospective Oliveira JLM et al Cardiovascular Ultrasound 2009;7:24
  • 18. 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% Oliveira JLM et al Cardiovascular Ultrasound 2009;7:24
  • 19. Warranty Serial testing? Low cardiac event rate within 2 years after normal stress myocardial perfusion or echo studies progressive atherosclerosis Bax et al Diabetes Care 2007;30:2729-36
  • 20. Suspect CAD Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 21. Suspect CAD Asymptomatic Selective Myocardial ischemia perfusion imaging assessment Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 22. Suspect CAD Asymptomatic Mild to moderate symptoms CCS Class I, II Selective Myocardial ischemia perfusion imaging assessment Normal or single segment abnormal Optimal medical therapy BP <130/80 OMT LDL <70 HbA1c <7% Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 23. Suspect CAD Asymptomatic Mild to moderate symptoms CCS Class I, II Selective Myocardial ischemia perfusion imaging assessment Normal or single Multisegmental segment abnormal abnormalities Optimal medical therapy Coronary BP <130/80 OMT angiography LDL <70 HbA1c <7% Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 24. Suspect CAD Asymptomatic Mild to moderate Significant symptoms symptoms CCS Class III, IV CCS Class I, II Selective Myocardial ischemia perfusion imaging assessment Normal or single Multisegmental segment abnormal abnormalities Optimal medical therapy Coronary BP <130/80 OMT angiography LDL <70 HbA1c <7% Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 25. Who should be screened for CAD? When can revascularization be offered to patients on medical therapy? When does CABG offer benefits over PCI?
  • 26. BARI 2D P: 2368 T2DM with heart disease I: Prompt revascularization with intensive medical therapy vs intensive medical therapy alone O: Primary - all-cause mortality Secondary - composite of death, MI or stroke 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. Stratified 2x2 facto"al randomization Prompt Medical therapy revascularization CABG Insulin- Insulin- sensitization sensitization Prompt Medical therapy revascularization PCI Insulin-provision Insulin-provision therapy therapy BARI 2D Study Group. NEJM 2009;11:360(24):2503-15
  • 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. Non-fatal MI Revascularization grp 7.4% Medical therapy 14.6% BARI 2D Study Group. NEJM 2009;360(24):2503-15
  • 34. Myocardial Jeopardy Index (MJI) percentage of myocardial segments supplied by significantly diseased coronary arteries or their branches
  • 35. Coronary Significant symptoms CCS Class III, IV angiography Mild to moderate symptoms CCS Class I, II MJI = Myocardial Jeopardy Index Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 36. Coronary Significant symptoms CCS Class III, IV angiography Mild to moderate symptoms CCS Class I, II Normal or non-obstructive Optimal medical therapy BP <130/80 LDL <70 HbA1c <7% OMT MJI = Myocardial Jeopardy Index Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 37. Coronary Significant symptoms CCS Class III, IV angiography Mild to moderate symptoms CCS Class I, II Non- obstructive Normal or non-obstructive Optimal medical therapy BP <130/80 LDL <70 HbA1c <7% OMT MJI = Myocardial Jeopardy Index Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 38. Coronary Significant symptoms CCS Class III, IV angiography Mild to moderate symptoms CCS Class I, II Non- obstructive Normal or Obstructive non-obstructive AND low MJI Optimal medical therapy Deferred BP <130/80 revascularization LDL <70 + OMT HbA1c <7% OMT MJI = Myocardial Jeopardy Index Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 39. Coronary Significant symptoms CCS Class III, IV angiography Mild to moderate Obstructive symptoms CCS Class I, II Non- obstructive Normal or Obstructive Obstructive non-obstructive AND low MJI AND high MJI Optimal medical therapy Deferred Prompt BP <130/80 revascularization revascularization LDL <70 + OMT + OMT HbA1c <7% OMT MJI = Myocardial Jeopardy Index Fuster V & Farkouh ME. Circulation 2010;121:2540-52
  • 40. Who should be screened for CAD? When can revascularization be offered to patients on medical therapy? When does CABG offer benefits over PCI?
  • 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. Evidence-based appropriate therapy for CAD in diabetes by symptom and/or disease severity Rutter MK & Nesto RW. Heart 2010;96:1436-40
  • 43. original BARI study P: 1829 patients (most had unstable angina and multivessel disease) I: RCT CABG vs PCI O: 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 BARI Investigators. NEJM 1996;335:217-25
  • 44. Coronary Artery Revascularization P: in Diabetes (CARDia) 510 diabetics with multivessel or complex single-vessel CAD I: RCT CABG or PCI with abciximab and stenting O: 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 Kapur A et al. J Am Coll Cardiol 2010;55:432-40
  • 45. SYNergy between PCI with TAXus P: and cardiac surgery (SYNTAX) 1800 patients with complex left main or three-vessel disease (452 with diabetes) I: RCT CABG vs PCI (paclitaxel-eluting stents) Post hoc data for those with diabetes O: one-year data 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) Banning AP et al. J Am Coll Cardiol 2010;55:1067-75
  • 46. Future REvascularization Evaluation in Patients P: with Diabetes: Optimal Management of Multivessel Disease (FREEDOM) ~2058 patients with diabetes and multivessel disease I: RCT CABG vs DES stent PCI in the setting of optimal medical therapy O: Total and CVD mortality at 1-5 years Quality of life and cost-effectiveness Farkouh et al. Am Heart J 2008;155:215-23
  • 47. Coronary grafts bypass proximal segments of vessels taking many atheromatous lesions out of play Stents leave behind substantial coronary plaque JNJhealth “Coronary Stent Animation” 3 Sept 2008, http://www.youtube.com/watch?v=9FPapBbbS4o&feature=channel. Accessed 25 Oct 2010
  • 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. Who should be screened for CAD? When can revascularization be offered to patients on medical therapy? When does CABG offer benefits over PCI?
  • 50. #ank Y$ http://www.endocrine-witch.net