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ESC Congress 2004: Diabetes and the heart

The the Euro Heart Survey on the diabetic state of patients with coronary artery disease

What did the Euro Heart Survey on diabetes and the heart address?

The following questions was raised in this survey

1. How common is abnormal glucose regulation (diabetes mellitus or impaired glucose tolerance) in patients with coronary artery disease?

2. How are patients with coronary artery disease and diabetes managed compared to their non-diabetic counterparts?

3. How is the outcome for patients with coronary artery disease and newly detected glucometabolic pertubations?

What did the Euro Heart Survey on diabetes and the heart tell us?

1. Among patients with coronary artery disease (acute or stable) abnormal glucose regulation is in fact more common than a normal glucose regulation.

2. Although in general fairly well managed patients with coronary artery disease and diabetes are less often subjected to coronary angiography and interventions (by-pass surgery and coronary angioplasty). They also recieve some drugs less frequently than their non-diabetic counterparts. This may contribute to, but cannot fully explain their more dismal prognosis.

3. The prognosis, as reflected by death or non-fatal myocardial infarction, during one year of follow up was best for patients with coronary artery disease without any glucometabolic abnormality and most serious for those with already known diabetes mellitus. Patients with newly detected diabetes or impaired glucose tolerance had a prognosis that was significantly worse than patients without any glucometabolic pertubations, however, somewhat better than those with diabetes established since before.

How should the Euro Heart Survey influence clinical practice?

1. The glucometabolic state should be investigated in all patients with coronary artery disease. The best way is by means of an oral glucose tolerance test.

2. The use of evidence based treatment, in particular coronary interventions, should be improved in diabetic patients with coronary artery disease. The least they deserve is a treatment standard of similar standards as for non-diabteic patients.

3. New and gluco-metabolically oriented preventive measures should have the potential to improve the dismal prognosis for patients with coronary artery disease and abnormal glucose tolerance. Such management need to consider already known possibilities to prevent impaired glucose tolerance to deteriorate to diabetes, a more aggressive risk factor management already advocated for patients in whom glucometabolic pertubations are added to a traditional risk factor pattern. Besides new, glucometabolically oriented preventive measures should be tested in future clinical trials.

4. Guidelines sholuld be issued on the best way to diagnose and treat patients with coronary artery disease and dsturbed glucose tolerance.

Some details about the Euro Heart Survey on Diabetes and the Heart

The survey engaged 110 centres in 25 countries recruiting 4,196 patients referred to a cardiology department or outpatient clinic due to CAD. A total of 2 107 of these patients were admitted on acute basis while 2,854 had an elective consultation. Patient data were collected via a web-based case record form. An oral glucose tolerance test (ingestion of 75 gram glucose dissolved in 200 ml water with blood glucose measured in the fasting state before and two hours thereafter) was used for the characterisation of the glucose metabolism. Categorisation was made according to criteria established by WHO for normal and impaired glucose tolerance and diabetes mellitus respectively.

So far 2,000 of the patients have been followed during one year after their first consultation. Accordingly the report given at this congress is complete as regards the data from the first consultation and preliminary as regards the one year follow up.

Thirty one per cent of the 4196 patients had an alerady known diabetes mellitus. An oral glucose tolerance test was achieved from 1 920 patients without previously known diabetes. Of these patients 923 had acute and 997 a stable manifestation of cornary artery disease respectively.

In patients with acute admissions due to their coronary artery disease 36% had impaired glucose regulation and 22% newly detected diabetes. In the group with elective consultations (stable coronary artery disease) these proportions were 37% and 14%.

Attempts were made to see whether the actual glucometabolic state could have been disclosed by easily available data such as family history, age, gender, fasting glucose, HbA1c and HDL-cholesterol. The balance between sensitivity and specificity was, however, not at all satisfactory applying these parameters one by one or in different weighted combinations. In particular a large number of patients, with newly detected diabetes according to the oral glucose tolerance test, would have been classified as normal and a proportion of those with impaired glucose tolerance would also have remained undetected.

The overall treatment pattern was fairly good when compared to existing guidelines for the care of patients with various manifestations of cornary artery disease. However, patients with diabetes were in some respects less well cared for. This related in particular to invasive investigations and procedures.

Follow up data on 2,000 of the 4,196 patients shows that the prognosis for these patients are worse for those with acute than for those with stable coronary artery disease. Moreover already established diabetes had a higher mortality and more new myocardial infarctions during the year of follow up than those with normal glucose tolerance. Patients with newly detected glucose abnormalities (new diabetes or impaired glucose tolerance) had a significantly worse prognosis than those who were gluco-metabolically normal, however, somewhat more favourable than for those with diabetes known previously.

L Ryden (Stockholm, SE)

This press release accompanies both a presentation and an ESC press conference given at the ESC Congress 2004. Written by the investigator himself/herself, this press release does not necessarily reflect the opinion of the European Society of Cardiology

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