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Diabetes mellitus, glycoprotein IIb/IIIa blockade, and heparin: evidence for a complex interaction in a multicenter
N S Kleiman1, A M Lincoff, D J Kereiakes
1Baylor College of Medicine and the Methodist Hospital, Houston, Tex, USA. nkleiman@bcm.tmc.edu
Insights
Abciximab reduced major adverse events in diabetic patients after angioplasty, similar to nondiabetics. However, it did not reduce target vessel revascularization in diabetics, potentially due to heparin dosage or disease complexity.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Diabetic patients face higher risks of complications and ischemic events post-angioplasty compared to nondiabetics.
- The EPILOG study investigated the efficacy of abciximab in mitigating these risks in diabetic individuals.
Purpose of the Study:
- To evaluate the effectiveness of abciximab treatment in reducing major complications and ischemic events in diabetic patients undergoing angioplasty.
- To compare outcomes between diabetic and nondiabetic patients treated with abciximab.
Main Methods:
- Analysis of data from 2792 patients in the EPILOG multicenter study, with 638 identified as diabetic.
- Comparison of baseline characteristics and in-hospital and 6-month outcomes between diabetic and nondiabetic groups.
- Assessment of abciximab's impact on composite endpoints (death, myocardial infarction, revascularization) and target vessel revascularization, considering heparin dosage.
Main Results:
- Diabetic patients had distinct demographic and clinical profiles, including higher rates of three-vessel disease and prior bypass surgery.
- Abciximab significantly reduced the composite of death or myocardial infarction in both diabetic and nondiabetic patients.
- While abciximab reduced target vessel revascularization in nondiabetics, this effect was not observed in diabetics; standard-dose heparin showed marginal benefits over low-dose heparin in diabetics.
Conclusions:
- Abciximab treatment offers comparable reductions in death or myocardial infarction for diabetic and nondiabetic patients.
- The lack of significant reduction in target vessel revascularization among diabetics treated with abciximab warrants further investigation.
- Potential contributing factors for observed differences include variations in platelet function, disease severity, or patient management strategies between diabetic and nondiabetic populations.
Background:
After angioplasty, major complications and ischemic events occur more frequently in diabetic than nondiabetic patients. To determine whether treatment with abciximab is effective in reducing these events in diabetics, we analyzed characteristics and outcomes of diabetic patients enrolled in a large multicenter study (EPILOG).
Methods And Results:
Of 2792 patients enrolled, 638 (23%) were diabetic. Diabetic patients were older, shorter, and heavier; more likely to be female and have three-vessel disease, prior coronary artery bypass graft surgery, a history of hypertension, or a recent myocardial infarction; and less likely to be current smokers than their nondiabetic counterparts. During hospitalization, death, myocardial infarction, or urgent revascularization occurred in 7.1% of diabetics and 7.5% of nondiabetics. By 6 months, the composite of death and myocardial infarction had occurred in 8.8% of diabetic patients and 7.4% of nondiabetics, whereas death, myocardial infarction, or revascularization had occurred in 27.2% and 22.6%, respectively. Abciximab treatment reduced death or myocardial infarction among diabetic and nondiabetic patients (hazard ratios, 0.28 [95% confidence interval (CI), 0.13 to 0.57] and 0.47 [95% CI, 0.33 to 0.70] at 30 days for diabetics and nondiabetics, respectively, and 0.36 [95% CI, 0.21 to 0.61] and 0.60 [95% CI, 0.44 to 0.82] at 6 months for diabetics and nondiabetics, respectively). Abciximab reduced target vessel revascularization among nondiabetic patients (hazard ratio, 0.78 [95% CI, 0.63 to 0.96]) but not among diabetics (hazard ratio, 1.4 [95% CI, 0.94 to 2.08]). When standard- and low-dose heparin adjuncts were compared, diabetics receiving abciximab with standard-dose heparin had marginally greater reductions in the composite of death and myocardial infarction and in target vessel revascularization than diabetics assigned to abciximab with low-dose heparin.
Conclusions:
Abciximab treatment in diabetic patients led to a reduction in the composite of death and myocardial infarction, which was at least as great as that seen in nondiabetic patients. However, target vessel revascularization was reduced in nondiabetic but not diabetic patients. This effect may be associated in part with lower doses of heparin. These differences may be related to differences in the platelet and coagulation systems between diabetics and nondiabetics, the greater extent of coronary artery disease in diabetics, or patient selection and management factors.