Glycemic Control Status After Percutaneous Coronary Intervention and Long-Term Clinical Outcomes in Patients With Type 2 Diabetes Mellitus

Abstract

C ardiovascular disease is the major cause of mortality in patients with type 2 diabetes mellitus.1 Although intensive therapy to lower glucose has consistently been reported to reduce microvascular complications of type 2 diabetes mellitus, 2,3 whether intensive glycemic control reduces macrovascular complications and improves clinical outcomes remains controversial. 4,5 Limited data are available regarding the effect of intensive glycemic control for secondary prevention in patients with established cardiovascular disease, especially in those undergoing percutaneous coronary intervention (PCI). The association between baseline glycosylated hemoglobin A (HbA1c) at the time of PCI and clinical outcomes among diabetic patients was reported in a few studies with conflicting results. 6,7 Moreover, it is not known if glycemic control after PCI can improve cardiovascular outcomes, which is a more important issue than glycemic status at the time of PCI. Because diabetic patients account for more than a quarter of all patients undergoing PCI and have worse outcomes compared with nondiabetic patients, 8,9 determining the optimal strategy for glycemic control in these patients after PCI has substantial clinical implications. Therefore, we investigated the association between glycemic status as estimated by HbA1c measured 2 years after PCI and long-term cardiovascular outcomes in type 2 diabetic patients undergoing PCI using drug-eluting stents (DES).Background-Data on the association between glycemic control after percutaneous coronary intervention and clinical outcomes are limited and controversial in diabetic patients. Methods and Results-We studied 980 patients with type 2 diabetes mellitus undergoing percutaneous coronary intervention using drug-eluting stents. Based on 2-year glycosylated hemoglobin A (HbA1c) levels, we divided patients into 2 groups of HbA1c<7.0 (n=489) and HbA1c≥7.0 (n=491). Propensity score-matched analysis was performed in 322 pairs. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of cardiac death, myocardial infarction, repeat revascularization, or stroke. Median follow-up duration was 5.4 years. The 7-year incidence of MACCE was lower in the HbA1c<7.0 group than in the HbA1c≥7.0 group (26.9% versus 40.3%; adjusted hazard ratio, 0.75; 95% confidence interval, 0.57-0.98; P=0.03). After propensity score matching, the 7-year incidence of MACCE was still lower in the HbA1c<7.0 group than in the HbA1c≥7.0 group (27.5% versus 37.4%; hazard ratio, 0.71; 95% confidence interval, 0.52-0.97; P=0.03), mainly because of a reduction in repeat revascularization (19.9% versus 29.5%; hazard ratio, 0.66; 95% confidence interval, 0.47-0.93; P=0.02). In subgroup analyses, the benefit of glycemic control for MACCE was more prominent in patients with residual SYNTAX score (Synergy Between PCI With Taxus and Cardiac Surgery) >4 than in those with the residual SYNTAX score ≤4 (P interaction =0.004). Conclusions-HbA1c<7.0 measured 2 years after percutaneous cor...

Increased risk of cardiovascular mortality by strict glycemic control (pre-procedural HbA1c < 6.5%) in Japanese medically-treated diabetic patients following percutaneous coronary intervention: a 10-year follow-up study

“…Even though strict and multifactorial comprehensive management of atherosclerotic risk factors, such as obesity, smoking, lipid disorders and hypertension in secondary prevention of CV events in patients with diabetes is recommended [3], the prognostic implication of HbA1c level is still controversial and only a limited number of studies have addressed it with respect to CV mortality in patients with established coronary artery disease who underwent PCI. Moreover, most of previous studies binarized using 7.0% HbA1c and failed to show any significant differences in the incidences of adverse CV events between the groups [35][36][37][38][39][40], a finding which is consistent with that of this study. For a detailed evaluation of the prognostic impact of preprocedural HbA1c level, this study divided the participants into 5 groups with an almost equal distribution of patient numbers in each group, < 6.5%, 6.5-7.0%, 7.0-7.5%, 7.5-8.5% and ≥ 8.5%, allowing us to focus on the risk of lower HbA1c levels.…”

Impact of Long-term Glycosylated Hemoglobin in Patients with Acute Myocardial Infarction: a retrospective cohort study

“…Moreover, a post-trial study conducted by monitoring the UKPDS cohort for up to 10 years demonstrated the emergence of reductions in the risks of MI and death from any cause in the intensive therapy group 21 . Furthermore, a recent study of diabetic patients undergoing PCI showed that a HbA1c level <7.0% at 2 years was associated with a reduction in major cardiovascular events that was mainly attributed to revascularization 22 . However, only 20% of the patients had an AMI diagnosis at the time of the index PCI which limits the extension of the result to AMI patients.…”

Effects of Preoperative HbA1c Levels on the Postoperative Outcomes of Coronary Artery Disease Surgical Treatment in Patients with Diabetes Mellitus and Nondiabetic Patients: A Systematic Review and Meta-Analysis

“…Stroke. Ten studies reported on the incidence of stroke [24,26,29,31,[39][40][41][42][43][44]. The results of the meta-analysis showed that there was no significant difference in stroke incidence between diabetic patients with lower preoperative HbA1c levels and those with higher preoperative HbA1c levels after cardiac surgery (OR = 1:49, 95% CI 0.94-2.37, P = 0:37, and I 2 = 8%), as shown in Figure 4.…”