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How sweet is sweet enough for the heart? Ronan Canavan Consultant Diabetologist St Vincent's University Hospital & St Columcilles Hospital Slide 2 Disclosures No interests to declare & No conflict of interests to declare Slide 3 Lugduname: between 220,000 and 300,000 times as sweet as sucrose Slide 4 Outline Diabetes and the heart Glycaemic targets and the heart Glucose lowering treatments and the heart Slide 5 Summary QHow important is the relationship between diabetes and the heart? AVery QWhat HbA1c target should be aimed for in a patient with heart disease? AIt depends but 6.5% (47mM/M) if you can get there relatively easily QWhat is the best way of getting to 6.5% (47mM/M)? ALifestyle, lifestyle, lifestyle and metformin Slide 6 Slide 7 Slide 8 Slide 9 I beat anorexia Slide 10 An epidemic for the 21st century 23.0 36.2 57% 23.0 36.2 57% 14.2 26.2 85% 14.2 26.2 85% 48.4 58.6 21% 48.4 58.6 21% 43.0 75.8 76% 43.0 75.8 76% 7.1 15.0 111% 7.1 15.0 111% Ireland 2007 - 2015 40% increase 39.3 81.6 108% 39.3 81.6 108% 19.2 39.4 105% 19.2 39.4 105% Ref: Diabetes Atlas second edition, IDF 2003 Global projection for the diabetes epidemic: 2003-2025 (millions) Slide 11 Mechanisms by which glucose to damages the heart Accelerated coronary atherosclerosis Abnormalities favouring coronary thrombosis Platelet function Coagulation Fibrinolysis Endothelial function Autonomic neuropathy Left ventricular dysfunction Slide 12 Slide 13 Slide 14 complications of Type 2 diabetes develop over decades Recruitment 1977-1991 End of study Sept. 1997 Clinical Centres23 Type 2 diabetic patients5102 Person years follow-up53,000 Funding23 million UKPDS Slide 15 UK prospective diabetes study (UKPDS) Slide 16 Accord trial Slide 17 Slide 18 Slide 19 Advance trial Slide 20 Slide 21 a 17% reduction in events of non-fatal myocardial infarction (odds ratio 083, 95% CI 075093), and a 15% reduction in events of coronary heart disease (085,077093). intensive glucose control reduced the risk for cardiovascular disease (relative risk [RR], 0.90 [95% CI, 0.83 to 0.98]; Diabetologia. 2009 Nov;52(11):2288-98. Epub 2009 Aug 5. Intensive glucose control and macrovascular outcomes in type 2 diabetes. Turnbull FMTurnbull FM, Abraira C, Anderson RJ, Byington RP, Chalmers JP, Duckworth WC, Evans GW, Gerstein HC, Holman RR, Moritz TE, Neal BC, Ninomiya T, Patel AA, Paul SK, Travert F, Woodward M.Abraira CAnderson RJByington RPChalmers JP Duckworth WCEvans GWGerstein HCHolman RRMoritz TE Neal BCNinomiya TPatel AAPaul SKTravert FWoodward M The George Institute for International Health, University of Sydney, Sydney, NSW 2050, Australia. fturnbull@george.org.au Slide 22 Allocation to more-intensive, compared with less-intensive, glucose control reduced the risk of major cardiovascular events by 9% (HR 0.91, 95% CI 0.84-0.99), primarily because of a 15% reduced risk of myocardial infarction (HR 0.85, 95% CI 0.76-0.94). Mortality was not decreased. Slide 23 Slide 24 Slide 25 Lifestyle Slide 26 Slide 27 Slide 28 Conclusions QHow important is the relationship between diabetes and the heart? AVery QWhat HbA1c target should be aimed for in a patient with heart disease? AIt depends but 6.5% (47mM/M) if you can get there relatively easily QWhat is the best way of getting to 6.5% (47mM/M)? ALifestyle, lifestyle, lifestyle and metformin Slide 29