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AACE and ACC meetings provided updates for endocrinologists
AACE announced Resource Room on its website; COURAGE one of the most important trials of the year.
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The 16th Annual meeting of the American Association of Clinical Endocrinologists was held in Seattle from April 10 to 15. In-patient glycemic control and how to produce it was an important element of the meeting, as it was the focus of two separate satellite symposia, both very well attended.
A survey of the AACE membership last year showed that the Society’s members were quite active with in-patient diabetes care and wished to continue that involvement. In the symposia, numerous questions arose during and after the main presentations regarding the techniques for achieving good in-patient glycemic control and the scientific rationale for the targets to be met. The outstanding scientific database for the targets designated by the AACE/ADA Consensus Development Conference were discussed in detail and further debated during the question and answer sessions which followed both symposia.
Additionally, AACE announced that a Resource Room for In-Patient Glycemic Control will be added this month to the AACE website. This room will be divided into 12 areas and will provide scientific content and references and slide presentations regarding these 12 areas of interest, including the basic science background, the clinical data base and the order sets for various aspects of in-patient ICU and non-ICU management.
It is intended that this resource room will make endocrinologists thoroughly aware of the basis for and the means to achieve good in-patient glycemic control. These resources will be provided without charge to all AACE members and can be made available to all in-patient diabetes teams having an AACE member as part of the team.
COURAGE raises PCI concerns
One of the most important clinical trials this year for diabetic patients was not presented at the AACE meeting: the COURAGE – or Clinical Outcomes Utilizing Percutaneous Revascularization and Aggressive Guideline-Driven Drug Evaluation – trial.
This study of maximum medical management with and without PCI in patients with chronic stable coronary ischemia was presented several weeks earlier at the late-breaking session of the ACC Annual Meeting in New Orleans. Although not organized as a trial in diabetic patients per se, it has nevertheless important implications for the management of patients with diabetes.
COURAGE included 2,287 patients with chronic stable angina, randomized to intensive medical management or to the same intensive medical management with PCI. The primary endpoint was total mortality from any cause plus nonfatal myocardial infarction.
After four years of follow-up, 19% of the patients having PCI had a primary event whereas 18.5% of the medical management-only patients had a primary event. Thus, PCI provided no additional benefit to intensive medical management in the stable patient with ischemic coronary disease.
This finding has great importance to patients with diabetes, since the finding of the first BARI Trial noted increased mortality in diabetic patients after PCI as compared with coronary artery bypass grafting (CABG), if internal mammary implants were used. This entirely unexpected outcome is being further investigated in the BARI 2 Diabetes Trial, which will report shortly.
However, COURAGE raises further concern regarding PCI, especially in diabetes where PCI is already somewhat less useful, and emphasizes the likely success of intensive medical management for high-risk patients such as those with diabetes. In such patients, the lesions subjected to PCI are vastly outnumbered by smaller, unstable fatty plaques, which stud the intimal surface of the coronary circulation of high-risk patients. It is these smaller, high-risk plaques that proceed to ulceration and thrombosis and cause most of the coronary events seen subsequently. Thus, PCI does not treat the likely future offending plaque and may produce sufficient further endothelial damage so as to accelerate greatly processes of atherosclerosis even further in that arterial segment.
Although this is only a preliminary analysis of the impact of COURAGE upon the management of diabetic patients, the study result was well noted by the members of AACE, who are concerned with the management of those diabetic patients with extremely high risk for coronary events.
For more on COURAGE, click here.
For more information:
- Dr. Garber is Professor, Departments of Medicine, Biochemistry and Molecular Biology and Cellular and Molecular Biology at Baylor College of Medicine. He is also the Chief Medical Editor of Endocrine Today.