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Sergio Berti Fondazione CNR-Reg . Toscana G. Monasterio Ospedale del Cuore, Massa

Sergio Berti Fondazione CNR-Reg . Toscana G. Monasterio Ospedale del Cuore, Massa. The bitter fate of acute coronary syndrome in diabetics: diabetics have more adverse outcomes after PCI. Diabetes in 2000 and forecast for 2030. 500. 400. 366.000.000. 300. Prevalenza mondiale (%).

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Sergio Berti Fondazione CNR-Reg . Toscana G. Monasterio Ospedale del Cuore, Massa

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

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

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

  4. Earlymortality of diabetic and non-diabeticpatients with acute myocardialinfarction: Historicalperspective

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

  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 30 days 8.5% 5.4% 2.1% 1.1% Sean M. Donahoe, MD at al. JAMA. 2007;298(7):765-775

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

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

  12. Zona Lunigiana 58 Km 74 Km 55 Km

  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 STEMIour experience (1496 pts) * *= HbA1c 6>x<6.49

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

  18. Patients presenting with STEMIour center experience Overall Mortality DM- * Pre-diabetes DM+ Survival, % Log rank, p<0.001 forbothcomparisons Follow-up, days *= HbA1c 6>x<6.49

  19. …Worst outcome…WHY ? • Widespread and more aggressive atherosclerotic disease in patients with Diabetes • Lower response to the antiaggregantingagents • Greaterincidence of the “No reflow” phenomenon • Comorbidities • Less aggressive treatment strategies in diabeticpatients

  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 UA/NSTEMI P value < 0.001 Sean M. Donahoe, MD at al. JAMA. 2007;298(7):765-775

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

  23. Mechanismscontributing to plateletdysfunctionIn patients withdiabetesmellitus ASSOCIATED METABOLIC CONDITIONS DEFICIENT INSULIN ACTION HYPERGLYCAEMIA OTHER CELLULAR ABNORMALITIES Increased P-selectin expression Impaired response to NO and PGI2 PLATELET ENDOTHELIAL DYSFUNCTION Obesity Osmotic effect IRS-dependent factors: Increased intracellular Ca++ degranulation Dyslipidemia Activation of PKC Inflammation Decreased membrane fluidity by glycation of surface proteins Increased platelet turnover Increased intracellular Ca++ Upregulation of P2Y12 signalling Oxydative stress Increased P-selectin and GP expression P2Y12 ADP Increased production of TF Decreased NO and PGI2 production IRS-1 PKC Ca++ H2O ROS/NOS TF PGI2 NO Endothelial cells Ferreiro JL, Angiolllo DJ. Circulation 2011; 123: 798-813

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

  25. Diabetes and PrasugrelTRITON TIMI 38 Wiviott SD Circulation 2008;118;1626-1636

  26. PLATO diabetes: All-cause mortality 10 8 6 4 2 0 [James 2010:H,I] Diabetes Ticagrelor (n=2326) Clopidogrel (n=2336) HR (95% CI) = 0.82(0.66–1.01) 8.7% 7.0% p for interaction = 0.66 All-cause mortality (%) 5.0% 3.7% No diabetes Ticagrelor (n=6999) Clopidogrel (n=6952) HR (95% CI) = 0.77(0.65–0.91) 0 60 120 180 240 300 360 Days after randomisation 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] CI, confidence interval; HR, hazard ratio. James S, et al. Eur Heart J 2010;31:3006–3016.

  27. The “no reflow” phenomenon Multivariable Predictors of 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 % AbhiramPrasad, MD at al. ACC Vol. 45, No. 4, 2005 February 15, 2005:508–14

  29. Co-morbidities impact PVD, peripheral vessel disease; CHF congestive heartfailure 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 2005-2007 N= 24952 pts.

  31. What kind of stent? DES vs BMS

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

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

  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 preventcardiovascularevents in diabeticpatients? Betterglycemic control?

  36. VADT ACCORD Sospeso per mortalità elevata ADVANCE

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

  38. Diabetes and ACS: “dangerousliasons” • 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. Conclusions Improveantithromboticstrategy Acute and chronic tight glycemiccontrol Optimalrevascularizationstrategy Optimal management of LV dysfunction

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

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