,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, 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. 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, 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,0,0.5,1,1.5,2,2.5,7.8,11.1,Fasting glucose (mmol/L),OGTT (mmol/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 imaginedNewly detected dysglycemia relates to impaired prognosis,Implications of the European 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 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 - 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),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 imaginedNewly detected dysglycemia relates to impaired prognosisA 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 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 modificationfat 30% (satur 10%)exercise 30 min x3-5/weeksmoking cess 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 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 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,Conventional,Intensive,Extendend 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 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 statins if not contraindicated,