Driving implementation of new guidelines –

Driving implementation Driving implementation of new guidelines –of new guidelines –

an option for IDF an option for IDF Europe member Europe member

organisationsorganisations

www.easd.orgwww.escardio.org

Joint ESC/EASD Guidelines supporting IDF members (Euro Heart J: 2007; 28: 88-136)

GUIDELINES ON DIABETES, PRE-DIABETESAND CARDIOVASCULAR DISEASES

New ESC/EASD Guidelines

Euro Heart J: 2007; 28: 88-136

Task Force MembersTask Force Members

M Bartnik PLGreet van den Berghe BEJ Betteridge UKM-J de Boer NLF Cosentino ITB Jönsson SE

M Laakso SFK Malmberg SES Priori ITJ Östergren SEJ Tuomilehto SFI Thrainsdottir IS

Other contributorsOther contributors

I Vanhorebeek BEM Strambo-Badiale ITP Lindgren SEQ Qiao SF

Co-chairsCo-chairsLars Rydén and Eberhard StandlLars Rydén and Eberhard Standl



ReviewersReviewers

J W Deckers (CPG review coordinator) NL

M Bertrand FRB Charbonnel FRE Erdman GEE Ferrannini ITA Flyvbjerg DKH Golhlke GEJ R G Juanatey ESI Graham IR

P F Monteiro POK Parhofer DEK Pyörälä SFI Raz ISG Schernthaner AUM Volpe ITD Wood UK

European Heart Journal (2007) 28, 88 - 136

≅≅1 5001 500comments and/or suggestion comments and/or suggestion

Appointed by ESC and EASDAppointed by ESC and EASD


1.1. IntroductionIntroduction

2.2. Definition, classification and screening of diabetes Definition, classification and screening of diabetes and and pre-diabetic glucose abnormalitiespre-diabetic glucose abnormalities

3.3. Epidemiology of diabetes, impaired glucose Epidemiology of diabetes, impaired glucose homeostasis and cardiovascular riskhomeostasis and cardiovascular risk

4.4. Identification of subjects at high risk for Identification of subjects at high risk for cardiovascular cardiovascular disease or diabetesdisease or diabetes

5.5. PathophysiologyPathophysiology

6.6. Treatment to reduce cardiovascular riskTreatment to reduce cardiovascular risk

7.7. Management of cardiovascular diseaseManagement of cardiovascular disease


Table of contents (1)Table of contents (1)


1.1. Heart failure and diabetesHeart failure and diabetes

2.2. Arrhythmias – atrial fibrillation and sudden cardiac Arrhythmias – atrial fibrillation and sudden cardiac deathdeath

3.3. Peripheral and cerebrovascular diseasePeripheral and cerebrovascular disease

4.4. Intensive careIntensive care

5.5. Health economics and diabetesHealth economics and diabetes

6.6. ReferencesReferences


Table of contents (1)Table of contents (1)

Pocket guidelines Pocket guidelines available available

(Joint ESC / EASD guidelines)(Joint ESC / EASD guidelines)


New Guidelines of the European Society of Cardiology (Euro Heart J: 2007; 28: 88-136)

110 from 25 countries

n= 4 961n= 4 961

2- 6 weeks per centreFebruary 2003 to January 2004

Euro Heart Survey Diabetes and the HeartEuro Heart Survey Diabetes and the HeartParticipating centresParticipating centres

Type of centre:

47% hospital cardiology wards

45% hospital based outpatient clinics

8% outpatient clinics

(Bartnik et al Eur Heart J 2004; 25:1880-90)

NGT IFG IGT DM

Acuteadmission

n=923

389

(42%)

39

(4%)

294

(32%)

201

(22%)

Electiveconsultation

n=997

486

(49%)

50

(5%)

320

(32%)

141

(14%)

OGTT (0 min) <6.1 ≥6.1 and <7.0 <7.0 ≥7.0

OGTT (2 h) <7.8 <7.8 ≥ 7.8 and <11.1 or ≥11.1

Patients with CAD and no diabetes (OGTT cohort n=1,920)

Bartnik M, et al. Eur Heart J 2004;25:1880–90.

Euro Heart Survey Diabetes and the Heart– OGTT outcome

FINnish Diabetes Risk ScoreFINnish Diabetes Risk Score(FINDRISC)(FINDRISC)

to assess 10-year risk ofto assess 10-year risk oftype 2 diabetes in adultstype 2 diabetes in adults

Available atAvailable at

www.diabetes.fi/englishwww.diabetes.fi/english

Diagnosing glucometabolic disturbances Diagnosing glucometabolic disturbances

(Modified after Lindstrom & Tuomilehto(Modified after Lindstrom & TuomilehtoDiabetes Care. 2003;26:725)Diabetes Care. 2003;26:725)

http://www.diabetes.fi/english

Activity 150 min/weekActivity 150 min/week

Lifestyle 7 Metformin 14 Acarbose 11 Rosiglitazone 7

5-7% weight reduction5-7% weight reduction

Numbers need to treat during 3 years to prevent one case of diabetes

Lifestyle modification or pills?Lifestyle modification or pills?

Preventing type 2 diabetesPreventing type 2 diabetes

Lifestyle modification Structured educationStructured education

Smoking cessation ObligatorySmoking cessation Obligatory

BP <130 / 80 mm HgBP <130 / 80 mm Hg

Renal dysf <125/75Renal dysf <125/75

HbA1c (DCCT standard) HbA1c (DCCT standard) ≤ ≤ 6.5%6.5%

mmol/lmmol/l mg/dlmg/dlVenous plasma glucoseVenous plasma glucose <6.0<6.0 108 108

Cholesterol Cholesterol <4.5<4.5 175175 LDL LDL <1.8<1.8 7070 HDLHDL male >1.0; female >1.2male >1.0; female >1.2 40; 4640; 46

Triglycerides Triglycerides <1.7<1.7 150150


Treatment targetsTreatment targets

Variable Target

Diabetes Care 29; 2006: 1963-1972

ADA / EASD consensus: Management of hyperglycemia in type 2 diabetes

Coronary artery disease (CAD) and diabetes (DM)Coronary artery disease (CAD) and diabetes (DM)

Main diagnosis DMMain diagnosis DM± CAD± CAD

Main diagnosis CADMain diagnosis CAD± DM± DM

CAD unknownCAD unknownECG, Echocardiography,ECG, Echocardiography,

Exercise testExercise test

DM knownScreening nephropathy If poor glucose control

(HbA1c >6.5%)Diabetology consultation

DM unknownOGTT

Blood lipids & glucoseHbA1c

If MI or ACSaim for

normoglycemia

CAD knownECG, Echocardiography,

Exercise testPositive finding

Cardiology consultation

NormalNormalFollow upFollow up

AbnormalAbnormalCardiology consultation

Ischemia treatmentNoninvasive or invasive

Newly detectedNewly detectedDM or IGT

± metabolic syndromeDiabetology consultation

NormalNormalFollow upFollow up


Investigational algorithmInvestigational algorithm

© Prof. Eberhard Standl

14



Top 10 Recommendations (1)Top 10 Recommendations (1)

ESC Pocket Guidelines adapted from European Heart Journal (2007) 28, 88 - 136

• reach all treatment targets (e.g. for lipids, BP, glycemia) to reduce CV risk

• screen for diabetes and IGT in all CV patients with an oGTT, as in subjects with high risk scores

• Lifestyle counselling (150 min exercise/wk, weight loss 5-7%, no smoking) is the basis of any diabetes therapy and of prevention of diabetes and CV disease

• Patients with diabetes and acute coronary disease should be offered mechanical revascularisation together with all other guideline based therapy


15





• Coronary revascularisation should favor bypass surgery over percutaneous intervention (PCI)

• when PCI is done, drug-eluting stents should be used

• specific risk assessment of diabetes patients with CV disease should screen for CAN, HF, arrhythmias, hypotension, PVD (Doppler), and (micro-) albuminuria

• strict BG control with intensive insulin therapy improves outcome of critically ill and cardiac surgery patients


16





• multifactorial therapy (lipid normalisation, tight control of HBP, near-normal glycemic control, antipalatelet therapy) is cost effective in preventing complications in patients with diabetes and CV disease

• the joint approach of cardiologists and diabetologists is mandatory for the sake of the millions of patients with diabetes, prediabetes and CV disease in view of the huge overlap between cardiovascular and metabolic diseases

Pocket guidelines: dri-Pocket guidelines: dri-ving implementation ving implementation - big chance for IDF - big chance for IDF

member member organisations organisations


New ESC/EASD Guidelines (Euro Heart J: 2007; 28: 88-136)

The problem is huge and can be solved only in The problem is huge and can be solved only in interdisciplinary cooperationinterdisciplinary cooperation

Guideline implementation meetings on a national or Guideline implementation meetings on a national or regional level help strengthen the competence and regional level help strengthen the competence and

visibility of diabetes organisations visibility of diabetes organisations

The guidelines are a simple, but excellent tool to The guidelines are a simple, but excellent tool to diagnose many undiagnosed patients with diabetesdiagnose many undiagnosed patients with diabetes

Implementation of the guidelines should improve the Implementation of the guidelines should improve the quality of care and the outcome of the millions of people quality of care and the outcome of the millions of people

with diabeteswith diabetes


Big chance for IDF member Big chance for IDF member organisationsorganisations


19

Escape the BIG WAVE:

UNite for DIABETES

A campaign of the International Diabetes Federation IDF, also supported by the German Diabetes Union DDU and the National Actionforum on Diabetes NAFDM


20

The Growing Diabetes Epidemic

Complications

• Diabetes is among the leading causes of kidney failure and neuropathy*

• CVD accounts for 75% of all deaths among diabetes patients in Europe*

• Diabetes is the main cause of partial vision loss and blindness in people over 20 in Europe*

• Diabetes stimulates various socio-psychological conditions

Statistics

• Diabetes is a leading cause of death in Europe*

• Currently, there are 30 million people in the enlarged Europe living with diabetes

• By 2025, the number of people with diabetes is expected to rise by 20% in Europe*

*WHO Report, 6 May, 2004

Guideline Guideline implementation implementation

- a must- a must


New ESC/EASD Guidelines (Euro Heart J: 2007; 28: 88-136)


22


23

RECORD-InterimsanalyseErgebnisse (adjudicated Events)

• Kein signifikanter Unterschied zwischen Rosiglitazon-Kombinationen und der Kombination Metformin+Sulfonylharnstoff

• Trotz erhöhter Rate von Herzinsuffizienz-Fällen keine Erhöhung der Ereignis-Rate insgesamt

*kardiovaskuläre Hospitalisierung oder Tod

0,830,97 (0,73–1,29)9693CV-Tod, Myokardinfarkt,Schlaganfall

0,0062,24 (1,27–3,97) 1738Herzinsuffizienz

0,501,16 (0,75–1,81)3743Myokardinfarkt

0,46

0,63

0,83 (0,51–1,36)

0,93 (0,67–1,27)

35

80

29

74

Tod

•CV

•Gesamt

0,431,08 (0,89–1,31)202217Primärer Endpunkt*

P-WertHazard Ratio (95% CI)

MET+SU (n=2227)

RSG+MET od. RSG+SU (n=2220)

Home et al. New Eng J Med 2007, NEJMoa073394

Genetic Background of Type 2 Diabetes

Total effect

Weighted total effect

Advantage BG-SM Advantage non-BG-SM

HbA1c differences between groups

Sarol et al; Curr Med Res opin 21(2005) 173-84

Impact of blood glucose self monitoring(BG-SM) on HbA1c in patients with

Type-2-diabetes without insulin treatment

Driving implementation of new guidelines –

Documents

Transcript of Driving implementation of new guidelines –