Coronary revascularisation in insulin-dependent diabetic patients with chronic renal failure

Area of Science:

• Cardiology
• Nephrology
• Diabetology

Background:

• Insulin-dependent diabetic patients undergoing renal transplantation evaluation often have significant coronary artery disease (CAD).
• Substantial CAD in this population is associated with poor 2-year survival (<50%).
• Management of asymptomatic or minimally symptomatic CAD in these patients is controversial.

Purpose of the Study:

• To investigate whether coronary artery revascularisation reduces the combined incidence of unstable angina, myocardial infarction, and cardiac death.
• To assess the impact of revascularisation versus medical management on cardiovascular outcomes in selected diabetic renal transplant candidates.

Main Methods:

• Coronary angiography was performed on 151 insulin-dependent diabetic candidates for renal transplantation.
• 31 patients with severe CAD (stenosis >75%), atypical/no chest pain, and preserved ejection fraction were identified.
• 26 patients were randomized to medical treatment (calcium-channel blocker + aspirin) or revascularisation (angioplasty/bypass surgery).

Main Results:

• Revascularisation significantly decreased cardiovascular endpoints compared to medical management (2/13 vs 10/13 patients, p < 0.01).
• Medical management was associated with a higher incidence of cardiovascular events, including 4 deaths from myocardial infarction.
• The median follow-up was 8.4 months.

Conclusions:

• Coronary revascularisation appears to decrease cardiac morbidity and mortality in insulin-dependent diabetic patients with chronic renal failure and asymptomatic severe coronary artery stenoses.
• Screening for silent coronary artery disease is suggested for diabetic patients being considered for renal transplantation.
• Revascularisation may be a beneficial strategy for this high-risk population.