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 Presenter report:
Patel, Anushka (Australia)
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In ADVANCE, 11,140 patients with type 2 diabetes from 20 countries were randomized to a fixed combination of perindopril and indapamide, or matching placebo. and were followed for an average of 4.3 years. Overall, the study found that routine treatment with perindopril-indapamide, regardless of initial blood pressure level, was associated with significant reductions in all-cause mortality, cardiovascular death, and other vascular outcomes. In the current analyses, we sought to investigate the risks of serious clinical outcomes associated with atrial fibrillation (AF) in patients with diabetes, and the effects of routine blood pressure lowering on these outcomes, in presence or absence of AF.
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After multivariate adjustment, the presence of AF at baseline was associated with a 71% (95% CI 40-108%, P<0.0001) greater risk of all-cause mortality, and comparable higher risks of cardiovascular death, coronary and cerebrovascular events and heart failure (all P<0.03). Routine treatment with a fixed combination of perindopril and indapamide produced similar relative, but greater absolute, risk reductions for all-cause and cardiovascular mortality in patients with AF, compared to those without AF. For example, the number needed to treat with perindopril-indapamide for 5 years to prevent one cardiovascular death was 40 for patients with AF, and 118 for patients without AF at baseline.
In conclusion, AF is associated with substantially increased risks of total mortality and cardiovascular events in patients with type 2 diabetes, and does not alter the relative treatment benefits obtained from routine blood pressure lowering. AF in these patients should be regarded as a marker of particularly adverse outcome and prompt aggressive management of all risk factors.
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 Discussant report:
Le Heuzey, Jean-Yves (France)
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| This presentation deals with the problem of whether atrial fibrillation is a factor or a marker of cardiovascular risk. |
Many comorbidities may be observed in patients with atrial fibrillation: hypertension, coronary artery disease, heart failure, obesity, sleep apnea syndrome, dyslipidemia and, of course, diabetes. The importance of diabetes in atrial fibrillation patients is well known: in the CHADS2 score, D means diabetes.
The high prevalence of diabetes has been observed in major studies on atrial fibrillation: 20% in AFFIRM, 21% in AF-CHF. The results presented show significant differences, after adjustment, in terms of occurrence of major cerebro-vascular events, all-cause mortality, cardiovascular death, occurrence of major coronary events and occurrence of heart failure.
This study has limitations, however: the anticoagulation rate is very low (26 %), as these patients with a high risk are candidates for an efficient anticoagulation by antivitamin K antagonists. The other limitation is the mode of atrial fibrillation diagnosis. The authors report a validation of atrial fibrillation diagnosis by a central review of 1000 randomly selected ECGs. The investigator diagnosis of atrial fibrillation sensitivity is only 79.4 %. Clearly some patients with silent atrial fibrillation were included in the group considered as “no atrial fibrillation”.
Conclusion: This study clearly shows that atrial fibrillation is a predictor of mortality in type 2 diabetes patients. It suggests that the patients who are at the highest risk are those who will obtain the best benefit from the treatment. The limitations concern the accuracy of atrial fibrillation diagnosis and the quality of antithrombotic treatment.