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The bitter fate of acute coronary syndrome in diabetics: diabetics have more adverse outcomes after PCI Sergio Berti Fondazione CNR-Reg. Toscana G. Monasterio.

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Presentation on theme: "The bitter fate of acute coronary syndrome in diabetics: diabetics have more adverse outcomes after PCI Sergio Berti Fondazione CNR-Reg. Toscana G. Monasterio."— Presentation transcript:

1 The bitter fate of acute coronary syndrome in diabetics: diabetics have more adverse outcomes after PCI Sergio Berti Fondazione CNR-Reg. Toscana G. Monasterio Ospedale del Cuore, Massa

2 Diabetes in 2000 and forecast for 2030 171.000.000 366.000.000 0 500 400 300 200 100 Prevalenza mondiale (%) Wild S et al. Diabetes Care 2004; 27: 1047-1053 forecast

3 Hossain P et al. N Engl J Med 2007; 356: 213-215 Diabetes in 2000 and forecast for 2030

4 Early mortality of diabetic and non-diabetic patients with acute myocardial infarction: Historical perspective

5 OASIS Registry Malmberg K et al, Circulation 2000;102:1014 Diabetes CVD(+) Diabetes CVD(-) No Diabetes CVD(+) No Diabetes CVD(-) 69 Hosp. 8013 Pts UA/NSTEMI

6 Diabetes and Mortality Following Acute Coronary Syndromes Sean M. Donahoe, MD at al. JAMA. 2007;298(7):765-775

7 Pooled TIMI Trials Sean M. Donahoe, MD at al. JAMA. 2007;298(7):765-775

8 Cumulative Incidence of All-Cause Mortality Through 1 Year After ACS Sean M. Donahoe, MD at al. JAMA. 2007;298(7):765-775

9 Cumulative Incidence of All-Cause Mortality Through 1 Year After ACS Sean M. Donahoe, MD at al. JAMA. 2007;298(7):765-775 2.1% 8.5% 1.1% 5.4% 30 days

10 Cumulative Incidence of All-Cause Mortality Through 1 Year After ACS Sean M. Donahoe, MD at al. JAMA. 2007;298(7):765-775 7.2% 3.1% 13.2% 8.1% 1 year

11 STEMI network Massa-Carrara / Versilia Spoke E 55 km

12 Zona Lunigiana

13 Matrix Network STEMI 1496 pts

14 Heart Hospital: STEMI network: Door to balloon

15 Heart Hospital: STEMI network: 1 year follow-up mortality

16 Patients presenting with STEMI our experience (1496 pts) * * = HbA1c 6>x<6.49

17 Patients presenting with STEMI our center experience Overall Mortality Follow-up, days Survival, % DM- DM+ Log rank, p<0.001

18 Patients presenting with STEMI our center experience Overall Mortality Follow-up, days Survival, % Log rank, p<0.001 for both comparisons DM- DM+ Pre-diabetes * * = HbA1c 6>x<6.49

19 Widespread and more aggressive atherosclerotic disease in patients with Diabetes Lower response to the antiaggreganting agents Greater incidence of the No reflow phenomenon Comorbidities Less aggressive treatment strategies in diabetic patients …Worst outcome… WHY ?

20 Angiographic data in patients with and without Diabetes presenting with ACS All ACS P value < 0.001 Sean M. Donahoe, MD at al. JAMA. 2007;298(7):765-775

21 Angiographic data in patients with and without Diabetes presenting with ACS P value < 0.001 UA/NSTEMI Sean M. Donahoe, MD at al. JAMA. 2007;298(7):765-775

22 Angiographic data in patients with and without Diabetes presenting with ACS P value < 0.001 STEMI *P value 0.02 * * Sean M. Donahoe, MD at al. JAMA. 2007;298(7):765-775

23 Mechanisms contributing to platelet dysfunction In patients with diabetes mellitus PKC ROS/NOS IRS-1 Ca ++ TF PGI 2 NO Endothelial cells H2OH2O P2Y 12 ADP HYPERGLYCAEMIA Increased P-selectin expression Osmotic effect Activation of PKC Decreased membrane fluidity by glycation of surface proteins DEFICIENT INSULIN ACTION Impaired response to NO and PGI 2 IRS-dependent factors: Increased intracellular Ca ++ degranulation ASSOCIATED METABOLIC CONDITIONS Obesity Dyslipidemia Inflammation OTHER CELLULAR ABNORMALITIES PLATELETENDOTHELIAL DYSFUNCTION Increased platelet turnover Upregulation of P2Y 12 signalling Increased intracellular Ca ++ Oxydative stress Increased P-selectin and GP expression Increased production of TF Decreased NO and PGI 2 production Ferreiro JL, Angiolllo DJ. Circulation 2011; 123: 798-813

24 Diabetes and Clopidogrel Angiolillo DJ et al Diabetes 2005; 54:2430-5Angiolillo DJ J Am Coll Cardiol 2006; 48:298-304

25 Diabetes and Prasugrel TRITON TIMI 38 Wiviott SD Circulation 2008;118;1626-1636

26 PLATO diabetes: All-cause mortality CI, confidence interval; HR, hazard ratio. James S, et al. Eur Heart J 2010;31:3006–3016. Diabetes Ticagrelor (n=2326) Clopidogrel (n=2336) HR (95% CI) = 0.82(0.66–1.01) No diabetes Ticagrelor (n=6999) Clopidogrel (n=6952) HR (95% CI) = 0.77(0.65–0.91) 7.0% 8.7% 3.7% 5.0% [James 2010:H,I] All-cause mortality (%) Days after randomisation 060120180 240300360 10 8 6 4 2 0 All-cause mortality benefit with ticagrelor was consistent with the overall PLATO trial results [Wallentin 2009:J] No interaction between diabetes status and treatment was observed (p=0.66) [James 2010:G,H] p for interaction = 0.66

27 Multivariable Predictors of the No-Reflow Phenomenon The no reflow phenomenon Iwakura et al. JACC Vol. 41, No. 1, 2003 January 1, 2003:1–7

28 The no reflow phenomenon Myocardial Blush Grade Incidence % Abhiram Prasad, MD at al. ACC Vol. 45, No. 4, 2005 February 15, 2005:508–14

29 Co-morbidities impact PVD, peripheral vessel disease; CHF congestive heart failure Solomon et al. Eur J Heart Fail 2010;12:1229-37

30 Under utilization of an early invasive treatment strategy in diabetic patients with ACS A nationwide study N= 24952 pts. 2005-2007

31 What kind of stent? DES BMS vs

32 DES vs BMS in diabetic patients Patti G Am J Cardiol 2008;102:1328 –1334 Restenosis TLR

33 Patti G Am J Cardiol 2008;102:1328 –1334 Death Stent Thrombosis MI DES vs BMS in diabetic patients

34 DES vs. BMS in Diabetic patients William B. Hillegass, MD, at al. Journal of the American College of Cardiology Vol. 60, No. 22, 2012

35 How to prevent cardiovascular events in diabetic patients? Better glycemic control?

36 Sospeso per mortalità elevata ACCORD VADT ADVANCE

37 N Engl J Med 2008;359:1577-89. UKPDS Trial

38 Diabetes and ACS: dangerous liasons 65% of Diabetic Patients dies following cardiovascular events 37% of ACS Patients is diabetic Diabetics with NSTEMI/UA, outcome is similar to non-diabetic patients with STEMI Future risk cardiovascular events: Diabetic Patients = non-diabetic patients with previous MI

39 Improve antithrombotic strategy Acute and chronic tight glycemic control Optimal management of LV dysfunction Optimal revascularization strategy Conclusions

40 The bitter fate of acute coronary syndrome in diabetics: diabetics have more adverse outcomes after PCI Sergio Berti Fondazione CNR-Reg. Toscana G. Monasterio Ospedale del Cuore, Massa


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