Percutaneous Coronary Intervention in Patients With Diabetes

Abstract

Over 170 million people worldwide have diabetes mellitus (DM), with an increasing proportion of these patients diagnosed in the developing world.1 Despite medical advances in prevention of coronary artery disease (CAD), the rising prevalence of DM threatens to increase the global burden of cardiovascular disease in the next 2 decades.2 Currently, patients with DM compose 25% to 30% of all patients undergoing coronary artery revascularization.3 Up to 60% of patients presenting with acute myocardial infarction may also have previously unrecognized diabetes. [4][5][6] The increasing recognition that DM is associated with adverse outcomes after coronary revascularization has led to the development of newer stent technologies and pharmacotherapies that may be differentially utilized in diabetic patients.This article reviews revascularization strategies, the current use of percutaneous coronary intervention (PCI), new developments in stent technology, and the importance of medical therapy after PCI among patients with DM. Timing of Revascularization and Revascularization StrategyPatients with DM have more diffuse and complex CAD than nondiabetic patients. 7 Revascularization of high-risk anatomy including proximal LAD stenosis is also associated with mortality benefit among patients with DM.8 Some have therefore advocated performing revascularization in diabetic patients regardless of symptoms. Balanced against these benefits is the observation that patients with DM who undergo revascularization experience less improvement in anginal symptoms compared to nondiabetics. 9 The BARI 2D trial was the first large randomized trial to enroll exclusively diabetic patients with CAD and stable angina. 10 This study demonstrated that an initial revascularization strategy plus optimal medical therapy yielded outcomes similar to optimal medical therapy with deferral of revascularization. Even with a deferred strategy, however, 38% of patients required revascularization during a 5-year follow-up period. 11Importantly, patients with left main coronary artery stenosis ≥ 50% or uncontrolled angina were excluded from BARI 2D and should undergo prompt revascularization. AbstractPatients with diabetes and coronary artery disease represent a challenging and growing subset of the population. Although surgical revascularization is the preferred treatment for patients with diabetes and multivessel coronary artery disease with stable angina, a significant proportion of diabetic patients undergo percutaneous revascularization due to comorbidities, presence of single-vessel disease, or presentation with myocardial infarction. The development of drug-eluting stents has significantly improved the results of percutaneous revascularization among diabetic patients, but a number of challenges remain, including higher rates of restenosis and stent thrombosis among diabetic patients. With current technologies, the outcomes of diabetic patients treated with noninsulin agents have approached that of nondiabetic patients. In comparison, patients with diab...

Factors associated with deferred lesion failure following fractional flow reserve assessment in patients with diabetes mellitus

“…Thus, whilst FFR is often seen as a binary assessment of ischemia, the absence of FFR detected ischemia in the setting of such rapid progression may not necessarily be reassuring. In the multivariate analysis in this study, insulin requiring DM and prior revascularization were identified as predictors of increased risk for DLF, both characteristics associated with increased burden, faster atherosclerosis progression, and worse outcomes .…”

Short term versus long term dual antiplatelet therapy after implantation of drug eluting stent in patients with or without diabetes: systematic review and meta-analysis of individual participant data from randomised trials

“…[11][12][13][14] Although new generation drug eluting stents have also been shown to provide improved safety and efficacy compared with balloon angioplasty, bare metal stents, and early generation drug eluting stents among patients with diabetes, such patients, particularly when they need treatment with insulin, have a high ischaemic risk. [15][16][17][18] Increased platelet and thrombin reactivity and decreased response to therapeutic agents including aspirin and clopidogrel have been described in patients with diabetes. 19 20 Whether diabetes should be taken into consideration in the selection of the most appropriate duration of DAPT remains unclear.…”

Occurrence and predictive risk factors associated with in-stent restenosis after drug-eluting stent implantation in diabetic patients: a prospective, clinical cohort study

“…Therefore, DM can result in vascular lesions arising from multiple mechanisms such as vasodilation disorder, platelet accumulation, thrombosis, inflammation, vascular remodelling, among others. Intensive blood glucose control can reduce the occurrence of cardiovascular events in type 1 DM, but no significant benefit was obtained in people with type 2 DM with an HbA1c level ≤ 7.0% [21,22]. Further research found that in the BMS implanted population, HbA1c levels were negatively correlated with BMS-ISR, but were not significantly correlated with DES-ISR [23].…”