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[Does diabetes change the anti-ischemic therapeutic options in the symptomatic coronary patient?]
1Service de cardiologie A, CHU Timone, rue Saint-Pierre, 13385 Marseille.
Insights
Treating diabetic coronary artery disease is complex. While medical therapy is effective, angioplasty and bypass surgery outcomes vary, with surgery potentially better for multivessel disease, though recent advances complicate comparisons.
Area of Science:
- Cardiology
- Diabetology
- Interventional Cardiology
Background:
- Assessing treatment outcomes for diabetic coronary patients is challenging due to undifferentiated diabetes types and angina stability.
- Medical therapies, including beta-blockers and antianginals, show efficacy and safety in diabetic populations.
- Conventional angioplasty yields poorer long-term results in diabetics compared to the general population, attributed to disease progression and restenosis.
Purpose of the Study:
- To evaluate and compare the effectiveness of medical treatment, coronary angioplasty, and coronary bypass surgery in diabetic patients with coronary artery disease.
- To analyze long-term outcomes and survival rates for different revascularization strategies in this specific patient group.
Main Methods:
- Review of existing studies including the ACIP, Morris et al., and BARI trials comparing medical, angioplasty, and surgical approaches.
- Analysis of outcomes based on diabetes type (Type 1 vs. Type 2), angina stability (stable vs. unstable), and disease extent (single vs. multivessel).
- Consideration of the impact of advancements like stenting and new antiplatelet agents on angioplasty outcomes.
Main Results:
- Medical therapy with beta-blockers and antianginals is well-tolerated and effective in diabetic patients.
- Coronary artery bypass surgery, particularly with internal mammary artery grafting, shows similar 5-year survival rates to non-diabetics.
- Stenting improves angioplasty results, making them comparable to the general population in specific subgroups, while surgery may offer better outcomes in multivessel disease.
Conclusions:
- Coronary artery bypass surgery appears superior for multivessel disease in diabetic patients, though this is debated due to trial limitations.
- Recent advancements in angioplasty, including stenting and new antiplatelet drugs, may alter the comparative effectiveness of revascularization strategies.
- Further research is needed to account for contemporary treatment advancements and refine treatment recommendations for diabetic coronary artery disease.
Abstract:
The assessment of results of medical treatment, angioplasty and coronary bypass surgery in diabetic coronary patients is difficult because of the absence of distinction in the subgroups of type 1 and 2 diabetes and of stable and unstable angina. With respect to medical therapy, betablockers are practically without deleterious effects and are effective in diabetic populations. The same is true of other antianginal drugs. Conventional coronary angioplasty is associated with poorer results than the general population in the long-term, partly because of progression of the coronary artery disease and partly because of an increased incidence of restenosis. The use of stents improves these results, which are similar to those of the general population with single vessel disease or those without proteinuria. Coronary bypass surgery, despite a certain perioperative morbidity, is associated with an identical survival rate at 5 years as non-diabetics, providing the internal mammary artery is grafted. The comparison between these methods is resumed in the ACIP study which opposes the 3 strategies, in Morris et al's study comparing medical and surgical approaches and, finally, in the recent BARI trial where patients were randomly allocated to angioplasty or surgery. It would appear that the surgical strategy gives better results in multivessel disease. However, many reserves have been voiced because of the small numbers of patients, the high number of excluded patients and the fact that recent progress in angioplasty with widespread use of stenting associated with the prescription of new antiaggregant drugs was not taken into account.
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