Download - Marco Roffi, MD, FESC, FACC
Marco Roffi, MD, FESC, FACC
Director
Interventional Cardiology Unit
University Hospital
GenevaSwitzerland
MIDAS
Multicenter International
Diabetes – Acute Coronary Syndromes
Registry
MIDAS: Background / RationaleMIDAS: Background / Rationale
• Significant number of non-ST-ACS patients is diabetic Significant number of non-ST-ACS patients is diabetic (20%)(20%)
• Number will increase „diabetes epidemics“Number will increase „diabetes epidemics“
• Diabetic patients areDiabetic patients are
– High-riskHigh-risk
– UndertreatedUndertreated
• Limited awareness of impact of diabetes on outcomes in Limited awareness of impact of diabetes on outcomes in ACSACS
• Registries have both scientific and educational validity Registries have both scientific and educational validity
Improving Awareness = Improving OutcomesImproving Awareness = Improving Outcomes
MIDAS : ObjectivesMIDAS : Objectives
• Monitor the adherence to evidence-based therapy Monitor the adherence to evidence-based therapy among diabetic patients with ACSamong diabetic patients with ACS
– GP IIb/IIIa inhibitors (extent, upstream use)GP IIb/IIIa inhibitors (extent, upstream use)– Early invasive strategyEarly invasive strategy– Drug-eluting stentsDrug-eluting stents
• Describe the outcomes of diabetic patients in the Describe the outcomes of diabetic patients in the current era of early invasive strategy and current era of early invasive strategy and aggressive antiplatelet therapyaggressive antiplatelet therapy
• Establish the prognostic validity of risk scores Establish the prognostic validity of risk scores (TIMI, GRACE) for the diabetic population(TIMI, GRACE) for the diabetic population
MIDAS: Design MIDAS: Design
• Prospective, international, multicenterProspective, international, multicenter
• Low-budget, supported by MSDLow-budget, supported by MSD
• Inclusion: diabetic patients with non-ST-ACSInclusion: diabetic patients with non-ST-ACS
• Target enrolment: 4000 patientsTarget enrolment: 4000 patients
• Primary outcome measure: in-hospital death or Primary outcome measure: in-hospital death or MIMI
Country ParticipatingCountry Participating
• Belgium Belgium
• SwitzerlandSwitzerland
• SpainSpain
• IsraelIsrael
• ItalyItaly
• NorwayNorway
• Soudi ArabiaSoudi Arabia
• NetherlandNetherland
• JordanJordan
• IndiaIndia
Preliminary results on 3412 patients enrolled Preliminary results on 3412 patients enrolled from 10/2005 to 5/2008from 10/2005 to 5/2008
Baseline CharacteristicsBaseline Characteristics
20%History PAD
13%Prior CABG
25%Prior PCI
13%History CHF
28±5BMI
79±14Weight (kg)
94%Diabetes Type II
63%Males
67±15Age
Baseline CharacteristicsBaseline Characteristics
10%History of stroke
79%Hypertension
62%Hyperlipidemia
19%Current smoker
15%Hystory of renal failure
36%Prior MI
Newly diagnosed diabetes 5.8%Newly diagnosed diabetes 5.8%
End - Organ DamageEnd - Organ Damage
11%
16%
8%
Retinop Nephrop Neurop
Predominant Symptom at PresentationPredominant Symptom at Presentation
78%
13%9%
Chest pain Dyspnea Other/None
Killip ClassKillip Class
75%
17%5% 3%
Class I Class II Class III Class IV
ECGECG
18% 17%
10%
47%
8%
0
10
20
30
40
50
Normal T Inv TransientST Elev
ST Depr Other
Troponin pos 69%Troponin pos 69%
Laboratory FindingsLaboratory Findings
1.3 ± 0.9 mg/dlCreatinine
7.5 ± 1.6*HbA1c
155 ± 61 mg/dlGlucose fasting
203 ± 85 mg/dlGlucose at pres
* available for 53% of patients* available for 53% of patients
Risk ScoresRisk Scores
• Mean TIMI risk score Mean TIMI risk score 3.93.9
• Mean GRACE risk score Mean GRACE risk score 140140
Risk category
Low
Intermediate
High
TIMI Risk Score
0-2
3-4
5-7
Risk category
Low
Intermediate
High
GRACE Risk Score
≤108
109-140
>140
Intermediate riskIntermediate risk Intermediate-high riskIntermediate-high risk
Diabetes MedicationDiabetes Medication
33%
61%
14%
40%
58%
12%
Presentation Discharge
Insulin
Oral Drugs
Diet
Type of Oral Hypoglycemic DrugsType of Oral Hypoglycemic Drugs
6%
68%
50%
4%7%
23%
92%
56%
6%9%
Presentation Discharge
Thiaz
Metformin
Sulfon
A-gluc-inhib
Other
GP IIb/IIIa Receptor InhibitorsGP IIb/IIIa Receptor Inhibitors
30%
2% 5%
Tirofiban Eptifibatide Abciximab
Utilization of GP IIb/IIIa Blockers in ACS
25%20%
14%
51%
27%
32%37%
NRMI GRACE CRUSADE CRUSADE EHS 00 EHS 04 MIDAS
conscons invasinvasMIDASMIDAS
31%31%
Use of GP IIb/IIIa Inhibitors Use of GP IIb/IIIa Inhibitors According to the Baseline RiskAccording to the Baseline Risk
43%
29%
44%
22%
40%
27%
TIMI 4-7 TIMI 1-3 Trop + Trop - ECG + ECG -
Angiography / RevascularizationAngiography / Revascularization
• Coronary angiography within 48 hours Coronary angiography within 48 hours 61%61%
• In-hospital PCIIn-hospital PCI60%60%
• In-hospital CABG In-hospital CABG 12%12%
• Patients transferred for angiography Patients transferred for angiography 14%14%
• Institutions with cath-lab Institutions with cath-lab 87%87%
• Cardiologists primarily Cardiologists primarily
in charge of the patientin charge of the patient 85%85%
Indications for Coronary AngiogrphyIndications for Coronary Angiogrphy
72%
20%
4% 4%
RoutineStrategy
RecurrentIschemia
Pos StressTest
Other
Extent of Coronary Artery DiseaseExtent of Coronary Artery Disease
8%
27% 26%
39%
0 CAD 1 CAD 2 CAD 3 CAD
EF 50 EF 50 ±± 12 % 12 %
Drug-Eluting Stent Use Drug-Eluting Stent Use
58%
30%
8%4%
DES BMS DES+BMS PTCA
In-Hospital MACEIn-Hospital MACE
3.1%
4.6%
Death MI
MIDAS - ConclusionsMIDAS - Conclusions
• Large, diabetic-ACS registry involving Europe, Large, diabetic-ACS registry involving Europe, Middle-East, and IndiaMiddle-East, and India
• Patients recruited mainly in centers with a Patients recruited mainly in centers with a catheterization laboratorycatheterization laboratory
• Sastisfactory use of evidence-based treatmentSastisfactory use of evidence-based treatment
– Early invasive strategyEarly invasive strategy
– GP IIb/IIIa receptor inhibitorsGP IIb/IIIa receptor inhibitors
– Drug-eluting stentsDrug-eluting stents
• Preliminary data analysis shows acceptable rates Preliminary data analysis shows acceptable rates of death or MIof death or MI