Several sessions held during last month's congress of the European Society of Cardiology (ESC; Sophia Antipolis, France) in Munich, Germany, focused on the diabetic state of patients with coronary artery disease. Presenters demonstrated that in patients with coronary artery disease, abnormal glucose regulation is more common than normal glucose regulation. Despite being in general fairly well managed, diabetic patients with coronary artery disease are less often subjected to coronary angiography and interventions such as coronary artery bypass surgery and angioplasty.
Panelists also said such patients receive some cardiovascular drugs less frequently than do their non-diabetic counterparts, which may contribute to, but not fully explain their more dismal prognosis. The panel discussion said the prognosis at one-year follow-up, as reflected by death or non-fatal myocardial infarction (MI), was best for patients with coronary artery disease without any glucometabolic abnormality and most serious for those with already known diabetes. Patients with newly detected diabetes or impaired glucose tolerance had a prognosis that was "significantly worse" than patients without any glucometabolic problems, but somewhat better than those with diabetes established prior to suffering an MI.
The presenters at the session strongly recommended that the glucometabolic state be investigated in all patients with coronary artery disease, preferably by means of an oral glucose tolerance test. They also urged that the use of evidence-based treatment, in particular coronary interventions, be improved in diabetic patients with coronary artery disease.
The panelists emphasized that physicians need to consider known possibilities to prevent impaired glucose tolerance from deteriorating into diabetes, which requires a more aggressive risk factor management, particularly improved lifestyle counseling to emphasize the effectiveness of physical activity and moderate weight loss. They said that guidelines on the best way to diagnose and treat patients with coronary artery disease and disturbed glucose tolerance "must advocate a better collaboration between people educated to take care of gluco-metabolic disturbances and those caring for the hearts of patients with such perturbations," according to an ESC account of the session.
Another presentation of study results suggested abnormal glycemia must be excluded by means of an oral glucose tolerance test in all patients with acute MI before discharge from the hospital. The GAMI (for Glucose Abnormalities in patients with Myocardial Infarction) study investigated whether abnormal glucose metabolism, defined as newly detected diabetes mellitus or impaired glucose tolerance, is more frequent in patients with acute MI without previous diabetes than in healthy controls from the same population. It also focused on whether abnormal glucose metabolism can be identified early after myocardial infarction and whether newly detected abnormal glucose metabolism assessed early after a myocardial infarction relates to long-term prognosis.
Findings presented by Eberhard Standl, head of the department of endocrinomolgy at Academic Teaching Hospital Schwabing and chair of the Munich Diabetes Research Institute, indicated that only a third of 164 patients without previously known diabetes but having suffered acute MI showed a normal glucose tolerance test at discharge from the hospital. Some 31% had previously unknown diabetes and 35% impaired glucose tolerance (IGT). At three-month follow-up of 144 patients, 25% had overt diabetes and 40% had IGT, numbers that remained unchanged at one-year follow-up of a smaller (124 patients) study population. Cardiovascular deaths – eight in number – had occurred only in patients with IGT and diabetes, and the researchers said there was a "striking preponderance" of major cardiovascular events in diabetics and even more impressively, in patients with IGT. They concluded that a "paradigm shift" in clinical practice is warranted given the findings that patients with impaired glucose tolerance are at particularly high risk for further cardiovascular events.
An ESC session chaired by Jean Marco, professor of cardiology at the University of Toulouse (Toulouse, France), and Professor K. Karsch, chair of cardiology of the University of Bristol (Bristol, UK), addressed the issue of thrombosis as the Achilles' heel of drug-eluting stents (DES). R. Virmani of the Armed Forces Hospital (Washington) presented data on patients in whom post-mortem investigations were performed at certain time intervals after implantation of DES. There not only was thrombosis at the site of the implanted stents, but also what one session observer termed "very impressive inflammatory response, which subsequently led to increased intimal proliferation."
Eberhard Grube, MD, chief of the department of cardiology and angiology at The Heart Center (Siegburg, Germany), presented data on about 12,000 patients in whom stents eluting sirolimus and paclitaxel had been implanted, showing an incidence of sub-acute thrombosis between 0.4% and 1.5% in different trials. Grube maintained that the use of drug-eluting stents is safe, but acknowledged that the ongoing problem of sub-acute thrombosis is "an important issue" for which a solution must be found.
The session also debated the question of whether DES will last, with systemic treatment possibly prevailing in the future. Ron Waksman, MD, of Washington Hospital Center (Washington), presented data on current trials studying different compounds to reduce restenosis after stent implantation. Citing a number of studies that included both anti-inflammatory and anti-mitotic compounds, he compared the outcome of the trials to DES and concluded, according to one observer, that the more promising approach may indeed be systemic treatment rather than using a localized drug-elution approach.
Buoyed by "very impressive short- and medium-term data" from the current trials, Keith Dawkins, MD, of Southampton, UK, espoused the view that the currently available DES technology will continue to prevail in the future. He maintained that the problem of thrombotic events could be overcome with more sophisticated anti-platelet and anti-thrombotic treatment.
Also at ESC, two new associations were created during the General Assembly of the society's membership – one for heart failure and the other for prevention and rehabilitation. The members also agreed to a new council on basic cardiovascular science, made up of eight working groups from non-ESC organizations. These organizations join the electrophysiology and echocardiography associations created last year.
Michal Tendera, incoming president of ESC, told the General Assembly: "The creation of these associations should be regarded as a milestone in the history of the society." He added: "We will continue to work together to develop a practical modus operandi, provide the most effective support, finalize the rules and regulations and fully integrate the associations within all existing ESC structures to let them grow and develop."
Tendera said the goal of the society would be to further integrate associations within the organization, form a common platform for basic science, enhance collaborations with national societies and strengthen the ESC's role in the political arena.
"Cardiologists alone cannot handle the problem of cardiovascular disease," he said. "There's a strong need to further develop external relations on the political level, with industry, other professional organizations and the press."
Other new initiatives included improving the electronic platform of ESC journals, simplifying the Euro Heart Survey program, promoting the concept of guidelines and producing an ESC Textbook of Cardiovascular Medicine.