il dr. giampaolo niccoli dichiara di non aver ricevuto ... gianpaolo.pdf · il dr. giampaolo...
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Il Dr. Giampaolo Niccoli dichiara di non aver ricevuto negli ultimi due anni compensi o finanziamenti da Aziende Farmaceutiche e/o Diagnostiche:
Dichiara altresì il proprio impegno ad astenersi, nell’ambito dell’evento, dal nominare, in qualsivoglia modo o forma, aziende farmaceutiche e/o denominazione commerciale e di non fare pubblicità di qualsiasi tipo relativamente a specifici prodotti di interesse sanitario (farmaci, strumenti, dispositivi medico-chirurgici, ecc.).
Standards of care nel trattamento dell’IMA
Dr. Giampaolo Niccoli
Department of Cardiovascular MedicineCatholic University of the Sacred Heart – Rome
Department of Cardiovascular Sciences
Glycemic disorders in cardiovascular diseases
Lancet 2010;375:2215–22
J Am Coll Cardiol 2004; 43:585-91
LA MALATTIA CORONARIOCA NEL DIABETICO E’ PIU’ SEVERA
LA MALATTIA CORONARIOCA NEL DIABETICO E’ PIU’ ESTESA
Niccoli G et al, EHJ, 2013
LA MALATTIA CORONARIOCA NEL DIABETICO E’ PIU’ VULNERABILE
Niccoli G et al, EHJ, 2013
Diabete: aumentato rischio di mortalità a lungo termine
STEMI
NSTEMI
Piccolo et Al - Effect of Diabetes Mellitus on Frequency of Adverse Events in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention Am J Cardiol 2016;118:345e352
Piccolo et Al - Effect of Diabetes Mellitus on Frequency of Adverse Events in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention Am J Cardiol 2016;118:345e352
Which are the therapeutic objectives in acute phase of ACS in diabetic patients?
1. Glycemic control
2. Antiaggregation
3. Revascularization
1. Glycemic control - 2017 ESC Guidelines on STEMI
2017 ESC Guidelines for the management of acute myocardial infarction in patients presentingwithST-segmentelevation - European Heart Journal (2018) 39, 119–177 doi:10.1093/eurheartj/ehx393
1. Glycemic control - 2015 ESC Guidelines on NSTEMI and 2013 ESC guidelines on diabetes and CVD
2013 ESC guidelines on diabetes
2015 ESC guidelines on NSTEMI
ESC Guidelines on diabetes, pre-diabetes,
and cardiovascular diseases developed in collaboration with the
EASD - European Heart Journal (2013) 34, 3035–
3087 doi:10.1093/eurheartj/e
ht108
2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting
without persistent ST-segment elevation - European Heart Journal
(2016) 37, 267–315 doi:10.1093/eurheartj/ehv320
2015
Suscettibilita’ all’ostruzione microvascolare Predisposizione acquisita
(Timmer et al, AJC, 2005)
(Iwakura et al, JACC, 2003)
Diabetes and acute hyper-glycaemia
Which are the therapeutic objectives in acute phase of ACS in diabetic patients?
1. Glycemic control
2. Antiaggregation
3. Revascularization
2. Antiaggregation (and DM)
Patti and al. -Antiplatelet Therapy in DM - Circulation Journal Vol.78, January 2014
)
18624 patients with ST-segment elevation or non-ST-segment elevation ACS. Among them 4662 (25%) were reported as having DM by the investigators
European Heart Journal (2010) 31, 3006–3016
Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin [PEGASUS]; NCT01225562) (J Am Coll Cardiol 2016;67:2732–40)
Circulation. 2008;118:1626-1636
13 608 subjects eligible for enrollment if they had moderate- to high-risk unstable angina (UA/NSTEMI), after medical treatment for STEMI with coronary anatomy known to be suitable for PCI, or before cardiac catheterization with planned primary PCI for STEMI
Circulation. 2008;118:1626-1636
Circulation. 2016;133:1772-1782. DOI: 10.1161/CIRCULATIONAHA.115.016783
Which are the therapeutic objectives in acute phase of ACS in diabetic patients?
1. Glycemic control
2. Antiaggregation
3. Revascularization
SYNTAX Trial: Death, Stroke and Myocardial infarction
Kappetein et al. EJCTS 2013
Huang et al. CARDIOLOGY 2014, Harskamp et al. Cardior Ther. 2013
The probability of several DES and BMSproducing the best outcomes in termsof efficacy and safety endpoints forpatients with diabetes.
Harskamp et al. Cardior Ther. 2013
Optimal Choice of Stent Type in Diabetic Patientswith Coronary Artery Disease
BMS(bare metal stent)
ZES(Zotarolimus-eluting stent)
PES(Paclitaxel-eluting
stent)
SES(Sirolimus-eluting
stent)
EES(Everolimus-eluting stent)
Conclusions
- A large part of patients presenting with NSTEMI-ACS and STEMI is affected by diagnosed or undiagnosed diabetes mellitus.
- A correct management of many factors in the acute phase of ACS, like correction of hyperglicemia, use of appropriate antiaggregation and a correct choice of revascularization can have an important impact on prognosis
- Discharge tehrapy should be probably tailored in diabetics including prolonged DAPT and new antglycemic drugs with cardioprotective outcome data
Thanks for your attention
Department of Cardiovascular Sciences
ESC guideline son myocardial revascularization: recommendations in diabetics
EHJ 2014
Huang et al. CARDIOLOGY 2014, Harskamp et al. Cardior Ther. 2013
Current evidence for optimal revascularizationstrategy in the diabetes patients ; RCT
3. Revascularization – 2013 ESC guidelines on diabetes,prediabetes and CVD
ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD - European Heart Journal (2013) 34, 3035–3087 doi:10.1093/eurheartj/eht108
3. Revascularization – 2015 ESC guidelines on NSTEMI
2015 ESC Guidelines for the management of acute coronary syndromes in
patients presenting without persistent ST-segment
elevation - European Heart Journal (2016) 37, 267–315
doi:10.1093/eurheartj/ehv320
Freedom Trial
CONCLUSION
- In patients with diabetes and advanced coronary disease,CABG was of significant benefit as compared to PCI. MI & allcause mortality were independently decreased, while strokewas slightly increased
- There was no significant interaction between the treatmenteffect of CABG on the primary endpoint according to SYNTAXscore or any other prespecified subgroup.
- CABG surgery is the preferred method of revascularization for patients with diabetes & multi-vessel CAD
Farkouh ME, et al. N Engl J Med.2012 Dec 20;367(25):2375-84
J Am Coll Cardiol 2010;55:432–40
2. Antiaggregation- 2015 ESC Guidelines on NSTEMI and 2017 ESC focused update on dual antiplatelet therapy
2015 ESC Guidelines for the management of acute coronary syndromes in patients
presenting without persistent ST-segment elevation - European Heart Journal (2016) 37,
267–315 doi:10.1093/eurheartj/ehv320
2017 ESC focused update on dual antiplatelet therapy n coronary artery disease developed in collaboration with EACTS - European Heart Journal (2018) 39, 213–254 doi:10.1093/eurheartj/ehx419
Circulation 2011; 123:798-813
2. Antiaggregation (and DM)
Patti and al. -Antiplatelet Therapy in DM - Circulation Journal Vol.78, January 2014
n engl j med 360;13 nejm.org march 26, 2009
Glycaemic control in acute coronary syndromes:prognostic value and therapeutic options
De Caterina et al- European Heart Journal (2010) 31, 1557–1564 doi:10.1093/eurheartj/ehq162 n engl j med 360;13 nejm.org march 26, 2009
Glycaemic control in acute coronary syndromes:prognostic value and therapeutic options
De Caterina et al- European Heart Journal (2010) 31, 1557–1564 doi:10.1093/eurheartj/ehq162
DIGAMI – 1 . 620 patients with DM and acute MI to a ≥24-h insulin –glucose infusion, followed by multi-dose insulin, or to routine glucose- lowering therapy.326 Mortality after 3.4 years was 33% in the insulin group and 44% (P 1⁄4 0.011) in the control group
DIGAMI 2 failed to demonstrate prognostic benefits.
1. Glycemic control – DIGAMI 1 and DIGAMI 2
What about the prognosis of patients with diabetes after AMI ?
Donahoe Sean M. et al- Diabetes and Mortality Following Acute Coronary Syndromes - JAMA, August 15, 2007—Vol 298, No. 7
Cumulative Incidence of All-Cause Mortality Through 1 Year After ACS
Donahoe Sean M. et al- Diabetes and Mortality Following Acute Coronary Syndromes - JAMA, August 15, 2007—Vol 298, No. 7
Introduction (1)
• Acute coronary syndromes (NSTE-ACS and STE-ACS) represent the main manifestationof ischemic heart desease, the most frequent cause of morbidity and mortality inEurope and worldwide.
• However in Europe there has been an overall trend for a reduction in ischaemic heartdisease mortality over the past three decade ischaemic heart disease now accountsfor almost 1.8 million annual deaths, or 20% of all deaths in Europe.
European Society of Cardiology: Cardiovascular Disease Statistics 2017 European Heart Journal (2017) 0, 1–72
Female Male
1. Standards of Medical Care in Diabetes 2018 Diabetes Care 2018;41(Suppl. 1):S86–S104 | https://doi.org/10.2337/dc18-S009
2. Piccolo et Al - Effect of Diabetes Mellitus on Frequency of Adverse Events in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention Am J Cardiol 2016;118:345e352
3 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation – Web Addenda
- Atherosclerotic cardiovascular disease is the leading cause of morbidity and mortality for individuals with diabetes and is the largestcontributor to the direct and indirect costs of diabetes1.
- Myocardial infarction represents the most common diabetes-relatedcomplication2.
- About 20-30% of European patients with NSTEMI-ACS have knowndiabetes mellitus; but a similar proportion of people may haveundiagnosed diabetes or impaired glucose tolerance3.
Introduction (2)
Glycemic disorders in cardiovascular diseases
State of the Art in Diabetes Management Lars Rydén Department of Medicine Karolinska Institutet Stockholm, Sweden –World Diabetes Day 14° November 2017
Diabetes and pathogenesis of CVD
ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD - European Heart Journal (2013) 34, 3035–3087 doi:10.1093/eurheartj/eht108
Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: full text - European Heart Journal Supplements (2007) 9 (Supplement C), C3–C74 doi:10.1093/eurheartj/ehl261
Which are the therapeutic objectives after discharge indiabetic patients with recent ACS?
1. Risk factors control and CV therapy
2. Use of antidiabeticdrugs with evidence of CV benefits
1. Risk factor control – 2013 ESC guidelines on diabetes,prediabetes and CVD
ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD - European Heart Journal (2013) 34, 3035–3087 doi:10.1093/eurheartj/eht108
1. Risk factor control - Glycemic ControlImpact of intensive vs. conventional glucose-lowering therapy
Significant improvement in end-stage renal disease was observed but no other difference in other microvascular end points. †Diabetes-related mortality
ACCORD, Action to Control Cardiovascular Risk in Diabetes; ADVANCE, Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation; CV, cardiovascular; HbA1c, glycosylated haemoglobin; N/R, not reported;
UKPDS, UK Prospective Diabetes Study; VADT, Veteran’s Affairs Diabetes Trial1. UKPDS Group. Lancet 1998;352:837–853; 2. Holman et al. N Engl J Med 2008;359:1565–1576; 3. Gerstein et al. N Engl J Med
2008;358:2545–2559; 4. ACCORD study group Diabetes Care 2016;39:701–708; 5. Patel et al. N Engl J Med 2008;358:2560–2572; 6. Zoungas et al. N Engl J
Med 2014;371:1392–1406; 7. Duckworth et al. N Engl J Med 2009;360:129–139; 8. Hayward et al. N Engl J Med 2015;372:2197–2206
n engl j med 358;6 www.nejm.org february 7, 2008
n engl j med 358;6 www.nejm.org february 7, 2008
Gæde P et al Diabetologia 2016;59:2298‒2307.
Cardiovascular therapy
Which are the therapeutic objectives after discharge indiabetic patients with recent ACS?
1. Risk factors control and CV therapy
2. Use of antidiabeticdrugs with evidence of CV benefits
Conclusions
Cardiovascular Disease and RiskManagement: Standards of Medical Care in Diabetesd2018 Diabetes Care 2018;41(Suppl. 1):S86–S104
| https://doi.org/10.2337/dc18-S009
n engl j med 373;22 nejm.org November 26, 2015
CANVAS/CANVAS-R
HR and 95% CI were estimated using Cox regression models with stratification according to trial and history of CVD for all canagliflozin groups combined versus placebo. CI, confidence interval; CV, cardiovascular; CVD, cardiovascular
disease; HF, heart failure; HR, hazard ratio; MI, myocardial infarction; PY, person-years; SGLT-2i, sodium-glucose cotransporter-2 inhibitor
Neal B et al. N Engl J Med 2017; doi: 10.1056/NEJMoa1611925
n engl j med 375;4 nejm.org July 28, 2016
n engl j med 375;19 nejm.org November 10, 2016
CI, confidence interval; CV, cardiovascular; MACE, major adverse cardiac event; MI, myocardial infarction
1. Marso SP et al. N Engl J Med 2016;375:311–322; 2. Marso SP et al. N Engl J Med 2016;375:1834–1844; 3. Zinman B et al. Cardiovasc Diabetol 2014;13:102; 4. Neal B et al. N Engl J Med 2017; doi:
10.1056/NEJMoa1611925
2016 European Guidelines on cardiovascular disease prevention in clinical practice
European Heart Journal (2016) 37, 2315–2381