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