Disclosures The Rapidly Changing Landscape Consulting of Diabetes - - PowerPoint PPT Presentation

4/16/2016 1

The Rapidly Changing Landscape

• f Diabetes Mellitus: What You

Need to Know

Joshua Beckman, MD Director, Section of Vascular Medicine Vanderbilt University

Disclosures

• Consulting

– Merck, Astra Zeneca, Novartis

• Research

– BMS

• Ownership

– Janacare, EMX

Agenda

• What we worry about
• What is happening now
• Why the change

5-Year Risk of Developing Ischemic Ulceration

ABI Risk of Ischemic Ulceration, % DM Present DM Absent

N=1244 men with claudication

Aquino R. J Vasc Surg. 2001;34:962-970.

| | | | | | | | |

50 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 10 20 30 40

| |

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Incidence of Contralateral CLI in Diabetic Subjects

Faglia, E. Diabetes Res Clin Prac. 2007:77: 445–450

Incidence of CLI and amputation of the contralateral limb in 533 diabetic pts hospitalized because of CLI from 1999 to 2003 and followed-up until 2005.

Critical Limb Ischemia

1.00 0.75 0.50 0.25 0.00 2 4 6 8 Years

Diabetes and Insulin Resistance is Present in Patients with CAD:

The Euro Heart Survey

A survey 110 centers in 25 countries of 4196 patients referred to a cardiologist for CAD (2107 acutely & 2854 electively). Patients without DM underwent oral glucose tolerance testing when stable.

Bartnik, M. Eur Heart J 2004; 25(21):1880

The Presence of CVD and CKD Strongly Predicts CVD Events

MI + Stroke (Events/1000 patient-years) Trials stratified by baseline CVD prevalence No CVD 10.6 Some CVD 24.6 All CVD 35.2 Trials stratified by baseline protienuria prevalence No proteinuria 6.5 Some proteinuria 19.1 All proteinuria 25.3

Preiss, D AHJ 2011;161:210-219

Analysis of 29 clinical trials of patients with diabetes evaluating the impact of Baseline cardiovascular disease and proteinuria on event rates

Annualized Rate of Diabetes Per 1000 Persons

Abraham, TM. Diab Care 2015: 38(3): 482-7

Trends in diabetes incidence in persons 40-55 years in Framingham Study participants.

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Prevalence and Incidence Trends for Diagnosed Diabetes Among Adults Aged 20 to 79 Years, United States, 1980-2012

Geiss JAMA. 2014;312(12):1218-1226. In 1997, the diabetes diagnostic criteria for fasting plasma glucose was lowered from 140 mg/dL or more to 126 mg/dL or more; in 2010, hemoglobin A1c was adopted for the diagnosis of diabetes. From the from the National Health Interview Survey (NHIS).

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

5 10 15 20 25 1 2 3 4 5 6 7 8 1958 62 66 70 74 78 82 86 90 94 98 02 06 10 13

Number with Diabetes (Millions) Percentage with Diabetes Year Percentage with Diabetes Number with Diabetes

Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2013

Provincial distribution diabetes prevalence in China in the last decade

• Zuo. Diabetes Research and Clinical Practice, 2014; 104:63–72

Prevalence of diabetes and per capita GRP in China

• Zuo. Diabetes Research and Clinical Practice, 2014; 104:63–72

4/16/2016 4 Meta‐analysis of Diabetes and Prior MI on Risk of Fatal and Non-Fatal MI

Bulugahapitya, U. Diabet Med 2009; 26:142-8

Coronary Revascularization During Hospitalization In Patients with Diabetes

Bina Ahmed et al. J Am Heart Assoc 2014;3:e001090

National Inpatient Sample, 2000–2010

Decrease Mortality Rates by Sex In Patients with Diabetes

Bina Ahmed et al. J Am Heart Assoc 2014;3:e001090

National Inpatient Sample, 2000–2010

Gregg EW et al. N Engl J Med 2014;370:1514-1523.

Trends in Age-Standardized Rates of Diabetes-Related Complications among U.S. Adults, 1990–2010.

Data from the National Health Interview Survey, the National Hospital Discharge Survey, the U.S. Renal Data System, and the U.S. National Vital Statistics System

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Effect of CT Angio CAD Screening in Diabetes Patients: DIAD 64

Nuhlestein, J JAMA 2014;213:2234-43

900 pts, DM 3-5 yrs, randomized to CTA or not. 38% normal.

Long-Term Outcomes in Diabetes Mellitus Related to Prolonging Clopidogrel After Coronary Stenting

Thukkani, AK. JACC, Volume 66, Issue 10, 2015, 1091–1101

28,849 patients undergoing stenting in VHA

Incidence of CVD, MI, or stroke with vorapaxar vs placebo stratified by diabetic

• status. TRA-2P

Matthew A. Cavender et al. Circulation. 2015;131:1047-1053

Zinman B et al. N Engl J Med 2015;373:2117-2128.

Cardiovascular Outcomes and Death from Any Cause in EMPA-REG OUTCOME

7028 patients with CV disease and diet controlled DM randomized To empagliflozin 10 or 25 mg daily or placebo

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Summary

• Diabetes and cardiovascular disease are

inextricably linked.

• Standard therapies proved to reduce

cardiovascular risk work in diabetes

– Blood pressure control – Statin therapy – Antiplatelet therapy

• Aggressive use of standard therapies would

reduce the cardiovascular disease burden substantially