How to treat diabetic patients with multivesseal disease in the DES era
P Pagnotta1, M Cabbavale, C Briguori
1IRCCS Humanitas, Via Manzoni 56, 20089 Rozzano-Milan, Italy.
Insights
For type 2 diabetes patients needing heart revascularization, coronary artery bypass grafting (CABG) shows better long-term results than percutaneous coronary intervention (PCI). Drug-eluting stents (DES) offer promise, but CABG still leads in reducing repeat procedures.
Area of Science:
- Cardiology
- Diabetology
- Vascular Surgery
Background:
- Type 2 diabetes mellitus (T2DM) patients comprise 25% of those needing myocardial revascularization.
- Diabetic patients often have complex coronary artery disease, depressed left ventricular function, and multiple risk factors, leading to worse outcomes.
- Existing guidelines favor coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) for T2DM patients with multivessel coronary artery disease.
Purpose of the Study:
- To evaluate the comparative effectiveness of different myocardial revascularization strategies in patients with type 2 diabetes.
- To assess the impact of drug-eluting stents (DES) versus CABG in diabetic patients.
- To identify factors influencing outcomes in diabetic patients undergoing revascularization.
Main Methods:
- Review of large randomized trials comparing CABG and PCI (bare metal stents and DES) in diabetic patients.
- Analysis of preliminary data from studies comparing DES with off-pump CABG in T2DM patients with multivessel coronary artery disease.
- Examination of outcomes including death, myocardial infarction, cerebrovascular events, and repeat revascularization rates.
Main Results:
- CABG demonstrated superiority over bare metal stent PCI in previous trials for diabetic patients.
- Preliminary data suggests no significant difference in 12-month death, myocardial infarction, or cerebrovascular events between DES and off-pump CABG.
- A 7.1% higher rate of repeat revascularization was observed with DES compared to CABG at 12 months.
- Diabetic retinopathy was identified as a predictor of poor outcomes in both PCI and CABG groups.
Conclusions:
- While DES show promise, CABG remains a favorable option for T2DM patients requiring multivessel revascularization due to a lower risk of repeat procedures.
- Further research is needed to fully elucidate the long-term benefits of DES versus CABG in this complex patient population.
- Diabetic retinopathy is a critical factor to consider when selecting a revascularization strategy for diabetic patients.
Abstract:
Patients with type 2 diabetes mellitus represent the 25% of those requiring myocardial revascularization. Choice of treatment in diabetic patients is much more controversial than in non-diabetics: this because coronary artery disease is more often complex and diffuse, left ventricular function is depressed, and concomitant multiple risk factors are present. These subset of patients experience worse outcomes than non diabetic patients undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI). Large randomized trials performed both in the early era of PCI and in the stent era suggest that CABG is superior to bare metal stent implantation in the treatment of diabetic patients with multivessel coronary artery disease. These findings are reflected in current guidelines, which favor CABG over PCI in most diabetics who require revascularization. However, substantial variability exists in practice patterns among individual hospital, suggesting a lack of clinical consensus. The major advantage of CABG over bare metal stent implantation in diabetic patients is the lower risk of repeat revascularization procedures through the follow-up. Better angiographic results have been demonstrated in the new era of drug-eluting stents (DES). Data from both the sirolimus and paclitaxel-eluting stents trials support the potential advantage of DES implantation both in diabetic and non-diabetic patients. Preliminary data from studies comparing DES versus CABG in diabetic patients with multivessel coronary artery disease suggests that 1) no significant difference exists in the 12-month rate of death, myocardial infarction and cerebrovascular events in patients treated with DES as compared to off-pump bypass surgery, 2) a difference of 7.1% in the rate of repeat revascularization at 12-month exists in favor of bypass surgery and 3) diabetic retinopathy identifies a subgroup with poor outcome after both percutaneous and surgical myocardial revascularization.
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