Need for improvement of screening and management of CAD patients with dysglycemia
Screening for Glucose Perturbations and Risk Factor Management in Dysglycemic Patients With Coronary Artery Diseased - A Persistent Challenge in Need of Substantial Improvement: A Report From ESC EORP EUROASPIRE V
Introduction and methods
Morbidity and mortality in patients with coronary artery disease (CAD) is considerably higher in presence of dysglycemia, including type 2 diabetes and the preceding state of impaired glucose tolerance (IGT) [1-3]. Although guidelines recommend that CAD patients should be screened for glucose perturbations, in an estimated two-third of CAD patients T2DM and IGT is unrecognized [4,5].
For more than 20 years, the EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events) cross-sectional surveys have compared diagnostic and therapeutic strategies to standards of care recommended by guidelines [3,6-10]. The EUROASPIRE IV survey emphasized the need for improvement in glucose perturbation screening, in lifestyle and risk factor improvements and in pharmacological treatment of CAD patients [3,8].
The EUROASPIRE survey assessed the prevalence of known and newly detected dysglycemia and management in CAD patients. ESC EORP EAV is a cross-sectional study conducted in 2016–2017 in 131 centers across 27 countries within the ESC. Patients with a first or recurrent diagnosis of CAD or who received treatment of CABG, PCI, acute MI or acute myocardial ischemia were eligible and 8261 patients enrolled 6-24 months before the investigation. Median time between index event and interview for data collection was 1.1 year (IQR: 0.8-1.6). An oral glucose tolerance test (OGTT) was performed using 75 g glucose in 200 mL water in the morning after ≥10 h of fasting. Dysglycemia was defined as presence of T2DM or IGT according to the WHO, based on glucose levels measured with OGTT. Plasma glucose (PG) was analyzed in the fasting state (FPG) and 2 h after the glucose load (2hPG) with a point-of-care technique.
- 29.7% of the study population had previously known diabetes. After exclusion of those not eligible for an OGTT, the test was performed in 4,440 patients. 729 (16.4%) Patients had newly diagnosed T2DM and 1095 (24.7%) had IGT.
- Of 729 patients with newly diagnosed T2DM, proportions identified by FPG were 58.5%. by 2hPG 52.5%, 19.2% by HbA1c, 90.7% by FPG plus 2hPG and 70% by HbA1c and FPG. Proportion identified by all 3 methods was 6.3%.
- 238 (30%) Patients with T2DM and 69.8% patients with IGT based on OGTT would not have been detected without this test.
- In the total CAD study population, presence of dysglycemia doubled from self-reported 29.7% to 58.8% following screening.
- A combination of drugs from 4 cardioprotective drug classes (including antiplatelet drugs, beta-blockers, RAAS blockers and lipid-lowering drugs) were prescribed in 49% of normoglycemic patients, 52.9% of those with newly diagnosed dysglycemia and 57.8% of patients with previously known diabetes.
- Control of risk factors was poor, with ~30% of patients in the 3 groups (no dysglycemia, newly detected dysglycemia, and previously known diabetes) reaching target levels of blood pressure (<130/80 mmHg) and LDL-c (<1.8 mmol/L).
- • Of previously known diabetes patients, 57% had been provided lifestyle advice, 75% were prescribed glucose-lowering agents (metformin most commonly prescribed (60%), followed by insulin (30%), SUs (19%), DPP-4 inhibitors (10%), GLP-1RAs (1%) and SGLT-2 inhibitors, glitazones, glinides (all at 1%).
- 79.8% of previously known T2DM patients reported to be under care of a cardiologist and 63.4% of a GP, 33.5% of diabetologist/endocrinologist, 4.4% of specialist cardiac nurse. Only 31.1% had been advised to attend a diabetes educational program and 24.1% had actively taken part.
Screening for diabetes by OGTT of CAD patients in the ESC EORP EUROASPIRE V study showed that in a large portion of patients diabetes or IGT was unrecognized: presence of dysglycemia doubled from self-reported 29.7% to 58.8% following screening. In addition, pharmacological management and achievement of risk factor targets in CAD patients was poor and requires urgent action considering the substantial higher CV risk of cardiometabolic patients.