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{{Chronic stable angina}}
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{{CMG}}<br/>
'''Associate Editors-In-Chief:''' Felipe Chaparro, M.D.; David M. Leder, M.D.; Brian C. Bigelow, M.D.


==Background==
{{CMG}}; '''Associate Editor(s)-In-Chief:''' Felipe Chaparro, M.D.; David M. Leder, M.D.; Brian C. Bigelow, M.D.


Patients with [[diabetes]] are more likely to have [[coronary artery disease|coronary artery disease (CAD)]] than non-diabetic patients. Furthermore, they are more likely to have multivessel disease, and more commonly present with atypical [[anginal]] symptoms, or even silent [[ischemia]].  Diabetic patients with CAD have a lower long-term survival rate than nondiabetic patients with CAD.
==Overview==
Patients with [[diabetes]] are more likely to have [[coronary artery disease|coronary artery disease (CAD)]] than non-diabetic patients. Furthermore, they are more likely to have multivessel disease, and they more commonly present with [[Chronic stable angina#Classification Scheme|atypical anginal symptoms]], or even [[ischemia|silent ischemia]].  Diabetic patients with [[CAD]] have lower long-term [[survival rates]] than non-diabetic patients with CAD.


==Goals of Treatment==
==Treatment in Diabetics==
===Goals of Treatment===
The main goal of treating diabetic patients with CAD is to decrease long term rates of death.  It is important to carefully select those patients who would benefit from [[revascularization]], and then to determine whether [[PCI]] or [[CABG]] is the preferred strategy.  Among patients who undergo revascularization therapy, the major goal is to prolong their event-free survival time.


The main goal of treating diabetic patients with CAD is to decrease long term rates of death.  It is important to carefully select those patients who would benefit from [[revascularization]], and in those patients who would benefit from revascularization, determine whether [[PCI]] or [[CABG]] is the preferred strategy.  Among patients who undergo revascularization therapy, the major goal is to prolong their event-free survival time.
==Treatment Choices==
===Medical Therapy===
===Medical Therapy===
Strategies that include aggressive risk factor modification such as [[glycemic]] control with a target [[HbA1C]] <7, [[LDL]] <100 mg/dl, [[blood pressure]] <130/80, smoking cessation, weight loss and regular exercise, showed no significant difference in the rates of death and major cardiovascular events compared to prompt [[revascularization]] at 5 years of surveillance for stable [[ischemic heart disease]].
Strategies that include aggressive risk factor modification such as glycemic control with a target [[HbA1C]] less than 7, LDL less than 100 mg/dl, blood pressure lower than 130/80, smoking cessation, weight loss and regular exercise, showed no significant difference in the rates of death and major cardiovascular events compared to prompt [[revascularization]] at 5 years of surveillance for [[Chronic stable angina|stable ischemic heart disease]].


'''Advantages of Medical Therapy:''' Medical treatment is a non-invasive treatment option which has shown similar outcomes at 5 years of surveillance for diabetic patients with stable [[ischemic heart disease]] when compared to [[PCI]] and [[CABG]].  
====Advantages of Medical Therapy====
[[Chronic stable angina medical therapy|Medical treatment]] is a non-invasive treatment option which has shown similar outcomes at 5 years of surveillance for diabetic patients with [[Chronic stable angina|stable ischemic heart disease]] when compared to [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] and [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]].  


===Percutaneous Revascularization===
===Percutaneous Revascularization===
Initial procedural success is similar in both patients with diabetes and those without; however, diabetic patients have higher rates of [[restenosis]] and lower rates of event-free survival than nondiabetic patients.  This is thought to be secondary to progression of disease in untreated areas and [[restenosis]] in treated areas.
Initial procedural success is similar in both patients with [[diabetes]] and those without; however, diabetic patients have higher rates of [[restenosis]] and lower rates of event-free survival than non-diabetic patients.  This is thought to be secondary to progression of disease in untreated areas and [[restenosis]] in treated areas.


After [[BMS|bare metal stent (BMS)]] placement, diabetic patients are more likely to have a decrease in event-free survival at 1 year with an increase in both overall and cardiac mortality.  These same findings were consistent in studies with longer follow-up periods where diabetic patients had a higher incidence of mortality and need for repeat revascularization.
====Bare Metal Stent====
After [[BMS|bare metal stent (BMS)]] placement, diabetic patients are more likely to have a decrease in event-free survival at 1-year with an increase in both overall and cardiac mortality.  These same findings were consistent in studies with longer follow-up periods where diabetic patients had a higher incidence of mortality and need for repeat revascularization.


[[DES|Drug-eluting stents (DES)]] are now used preferentially over BMS in most patients because they are associated with marked reductions in the incidence of restenosis and target lesion revascularization.  At 4-year follow-up in the TAXUS trial, treatment of diabetic patients with [[Paclitaxel]]-eluting stents (PES) compared with BMS was safe and effective, resulting in markedly lower rates of target lesion revascularization, with similar rates of death, [[myocardial infarction]], and [[stent thrombosis]].  As showed in several trials, like SIRIUS and SCORPIUS, diabetic patients treated with [[Sirolimus]]-eluting stents (SES) had better outcomes with a significantly lower rate of target lesion revascularization, decreased late luminal loss and major adverse cardiac events compared to those treated with bare metal stents.  A meta-analysis comparing the clinical efficacy of drug-eluting stents in diabetic patients concluded that the revascularization and major adverse cardiovascular events estimates are similar with both PES and SES.
====Drug Eluting Stent====
[[DES|Drug-eluting stents (DES)]] are now used preferentially over [[BMS]] in most patients because they are associated with marked reductions in the incidence of restenosis and target lesion revascularization.  At 4-year follow-up in the ''TAXUS trial''<ref name="pmid12515740">Grube E, Silber S, Hauptmann KE, Mueller R, Buellesfeld L, Gerckens U et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515740 TAXUS I: six- and twelve-month results from a randomized, double-blind trial on a slow-release paclitaxel-eluting stent for de novo coronary lesions.] ''Circulation'' 107 (1):38-42. PMID: [http://pubmed.gov/12515740 12515740]</ref>, treatment of diabetic patients with [[Paclitaxel|paclitaxel-eluting stents]] (PES) compared with BMS was safe and effective, resulting in markedly lower rates of target lesion revascularization, with similar rates of death, [[myocardial infarction]], and [[stent thrombosis]].  As showed in several trials, such as ''SIRIUS''<ref name="pmid14769686">Holmes DR, Leon MB, Moses JW, Popma JJ, Cutlip D, Fitzgerald PJ et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14769686 Analysis of 1-year clinical outcomes in the SIRIUS trial: a randomized trial of a sirolimus-eluting stent versus a standard stent in patients at high risk for coronary restenosis.] ''Circulation'' 109 (5):634-40. [http://dx.doi.org/10.1161/01.CIR.0000112572.57794.22 DOI:10.1161/01.CIR.0000112572.57794.22] PMID: [http://pubmed.gov/14769686 14769686]</ref> and ''SCORPIUS''<ref name="pmid17950142">Baumgart D, Klauss V, Baer F, Hartmann F, Drexler H, Motz W et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17950142 One-year results of the SCORPIUS study: a German multicenter investigation on the effectiveness of sirolimus-eluting stents in diabetic patients.] ''J Am Coll Cardiol'' 50 (17):1627-34. [http://dx.doi.org/10.1016/j.jacc.2007.07.035 DOI:10.1016/j.jacc.2007.07.035] PMID: [http://pubmed.gov/17950142 17950142]</ref>, diabetic patients treated with [[Sirolimus|sirolimus-eluting stents]] (SES) had better outcomes with a significantly lower rate of target lesion revascularization, decreased late luminal loss, and major adverse cardiac events compared to those treated with bare metal stents.  A meta-analysis comparing the clinical efficacy of drug-eluting stents in diabetic patients concluded that the revascularization and major adverse cardiovascular events estimates are similar with both PES and SES.<ref name="pmid18230778">Galløe AM, Thuesen L, Kelbaek H, Thayssen P, Rasmussen K, Hansen PR et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18230778 Comparison of paclitaxel- and sirolimus-eluting stents in everyday clinical practice: the SORT OUT II randomized trial.] ''JAMA'' 299 (4):409-16. [http://dx.doi.org/10.1001/jama.299.4.409 DOI:10.1001/jama.299.4.409] PMID: [http://pubmed.gov/18230778 18230778]</ref>


'''Advantages of Percutaneous Revascularization:''' PCI is generally associated with less [[morbidity]] and mortality than [[CABG]].  Given the dramatically lower rates of [[restenosis]] with drug-eluting stents, this approach is good for patients with focal one or two vessel disease, as long as the proximal [[LAD]] or [[left main]] are not involved.
====Advantages of Percutaneous Revascularization====
[[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] is generally associated with less [[morbidity]] and mortality than [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]].  Given the dramatically lower rates of [[restenosis]] with drug-eluting stents, this approach is good for patients with focal one or two vessel disease, as long as the [[LAD|proximal LAD]] or [[left main]] are not involved.


===Surgical Revascularization===
===Surgical Revascularization===
As with PCI, death, major adverse cardiac events, short and long-term outcomes tend to be worse in diabetic patients compared to nondiabetic patients. Outcomes with [[CABG|coronary artery bypass graft surgery (CABG)]] are generally better than those treated with PCI or medical management, especially for multivessel disease and if there is involvement of the [[left anterior descending artery]] and an [[internal mammary artery]] is used.
As with PCI, death, major adverse cardiac events, short and long-term outcomes tend to be worse in diabetic patients compared to non-diabetic patients. Outcomes with [[CABG|coronary artery bypass graft surgery ]] are generally better than those treated with PCI or medical management, especially for multivessel disease and if there is involvement of the [[left anterior descending artery]] and an [[internal mammary artery]] is used.


'''Advantages of Surgical Revascularization:''' While contemporary trials comparing [[revascularization]] with drug-eluting stents versus [[CABG]] in diabetic patients with multivessel disease are ongoing, the available data comparing PCI to CABG in this setting are in favor of CABG with regards to long term outcomes.
====Advantages of Surgical Revascularization====
While contemporary trials comparing [[revascularization]] with drug-eluting stents versus [[CABG]] in diabetic patients with multivessel disease are ongoing, the available data comparing PCI to CABG in this setting are in favor of CABG with regards to long term outcomes.


==Making a Selection==
===Making a Selection===
In diabetic patients, intensive medical treatment should be considered if the patient has [[stable angina]] that is not significantly interfering with the quality of life or for whom the procedure is not indicated to prolong life.
*In diabetic patients, intensive medical treatment should be considered if the patient has [[Chronic stable angina definition|stable angina]] that is not significantly interfering with the quality of life or for whom the procedure is not indicated to prolong life.


PCI with placement of drug-eluting stent(s) should be considered if the patient has:
*[[PCI]] with placement of drug-eluting stent(s) should be considered if the patient has:
*Single vessel disease
:*Single vessel disease
*2 vessel disease excluding the proximal LAD
:*Double vessel disease excluding the [[LAD|proximal LAD]]
*Older patients with significant [[comorbidities]]
:*Older patients with significant [[comorbidities]]
*Prior [[CABG]]
:*Prior [[CABG]]


[[CABG]] (especially if an [[IMA]] can be used) should be considered if the patient has:  
*[[CABG]] (especially if an [[IMA]] can be used) should be considered if the patient has:  
*3 vessel disease
:*Triple vessel disease
*Significant [[left main coronary artery]] [[stenosis]]
:*Significant [[Left main|left main]] [[CAD|coronary artery stenosis]]
*2 vessel disease with one of the lesions being a proximal left anterior descending (LAD) coronary artery lesion
:*Double vessel disease with one of the lesions being a [[LAD|proximal left anterior descending coronary artery]] lesion
*Significant coronary artery disease and also requires surgery for a heart valve
:*Significant [[coronary artery disease]] and also requires surgery for a heart valve


Regardless of treatment choice, all patients should have aggressive risk factor modification as well (i.e. [[antihypertensives]], lipid control, tobacco cessation, regular exercise and blood sugar control).
*Regardless of treatment choice, all patients should have aggressive [[Chronic stable angina secondary prevention|risk factor modification]] as well (i.e. [[Chronic stable angina treatment blood pressure control|blood pressure control]], [[Chronic stable angina treatment lipid management|lipid control]], [[Chronic stable angina treatment smoking cessation|tobacco cessation]], [[Chronic stable angina treatment weight management|weight loss]], [[Chronic stable angina treatment physical activity|regular exercise]] and [[Chronic stable angina treatment diabetes control|blood sugar control]]).


==Anticipated Outcomes==
===Anticipated Outcomes===
Resolution of both [[symptomatic]] and [[asymptomatic]] [[ischemia].
Resolution of both [[ischemia|symptomatic]] and [[ischemia|asymptomatic ischemia]].


==Other Concerns==
===Other Concerns===
Certain situations demand additional considerations.  If a patient had [[angina]] or [[ischemia]] despite optimal medical management, [[revascularization]] should be considered.  Also, if a patient has [[angina]] after having [[CABG]], [[PCI]] with placement of [[DES|drug-eluting stent(s)]] should be considered.  Furthermore, if a patient fails PCI, either through initial technical failure or repeated episodes of [[restenosis]], they should be considered for [[CABG]] – especially if an [[IMA]] can be used.
If a patient had [[Chronic stable angina definition|angina]] or [[ischemia]] despite [[Chronic stable angina medical therapy|optimal medical management]], [[Chronic stable angina revascularization|revascularization]] should be considered.  Also, if a patient has [[Chronic stable angina definition|angina]] after having [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]], [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] with placement of [[Chronic stable angina revascularization drug eluting stents|drug-eluting stent(s)]] should be considered.  Furthermore, if a patient fails PCI, either through initial technical failure or repeated episodes of [[restenosis]], they should be considered for CABG– especially if an [[IMA]] can be used.


==References==
{{reflist|2}}


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Latest revision as of 19:53, 6 February 2013

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Felipe Chaparro, M.D.; David M. Leder, M.D.; Brian C. Bigelow, M.D.

Overview

Patients with diabetes are more likely to have coronary artery disease (CAD) than non-diabetic patients. Furthermore, they are more likely to have multivessel disease, and they more commonly present with atypical anginal symptoms, or even silent ischemia. Diabetic patients with CAD have lower long-term survival rates than non-diabetic patients with CAD.

Treatment in Diabetics

Goals of Treatment

The main goal of treating diabetic patients with CAD is to decrease long term rates of death. It is important to carefully select those patients who would benefit from revascularization, and then to determine whether PCI or CABG is the preferred strategy. Among patients who undergo revascularization therapy, the major goal is to prolong their event-free survival time.

Medical Therapy

Strategies that include aggressive risk factor modification such as glycemic control with a target HbA1C less than 7, LDL less than 100 mg/dl, blood pressure lower than 130/80, smoking cessation, weight loss and regular exercise, showed no significant difference in the rates of death and major cardiovascular events compared to prompt revascularization at 5 years of surveillance for stable ischemic heart disease.

Advantages of Medical Therapy

Medical treatment is a non-invasive treatment option which has shown similar outcomes at 5 years of surveillance for diabetic patients with stable ischemic heart disease when compared to PCI and CABG.

Percutaneous Revascularization

Initial procedural success is similar in both patients with diabetes and those without; however, diabetic patients have higher rates of restenosis and lower rates of event-free survival than non-diabetic patients. This is thought to be secondary to progression of disease in untreated areas and restenosis in treated areas.

Bare Metal Stent

After bare metal stent (BMS) placement, diabetic patients are more likely to have a decrease in event-free survival at 1-year with an increase in both overall and cardiac mortality. These same findings were consistent in studies with longer follow-up periods where diabetic patients had a higher incidence of mortality and need for repeat revascularization.

Drug Eluting Stent

Drug-eluting stents (DES) are now used preferentially over BMS in most patients because they are associated with marked reductions in the incidence of restenosis and target lesion revascularization. At 4-year follow-up in the TAXUS trial[1], treatment of diabetic patients with paclitaxel-eluting stents (PES) compared with BMS was safe and effective, resulting in markedly lower rates of target lesion revascularization, with similar rates of death, myocardial infarction, and stent thrombosis. As showed in several trials, such as SIRIUS[2] and SCORPIUS[3], diabetic patients treated with sirolimus-eluting stents (SES) had better outcomes with a significantly lower rate of target lesion revascularization, decreased late luminal loss, and major adverse cardiac events compared to those treated with bare metal stents. A meta-analysis comparing the clinical efficacy of drug-eluting stents in diabetic patients concluded that the revascularization and major adverse cardiovascular events estimates are similar with both PES and SES.[4]

Advantages of Percutaneous Revascularization

PCI is generally associated with less morbidity and mortality than CABG. Given the dramatically lower rates of restenosis with drug-eluting stents, this approach is good for patients with focal one or two vessel disease, as long as the proximal LAD or left main are not involved.

Surgical Revascularization

As with PCI, death, major adverse cardiac events, short and long-term outcomes tend to be worse in diabetic patients compared to non-diabetic patients. Outcomes with coronary artery bypass graft surgery are generally better than those treated with PCI or medical management, especially for multivessel disease and if there is involvement of the left anterior descending artery and an internal mammary artery is used.

Advantages of Surgical Revascularization

While contemporary trials comparing revascularization with drug-eluting stents versus CABG in diabetic patients with multivessel disease are ongoing, the available data comparing PCI to CABG in this setting are in favor of CABG with regards to long term outcomes.

Making a Selection

  • In diabetic patients, intensive medical treatment should be considered if the patient has stable angina that is not significantly interfering with the quality of life or for whom the procedure is not indicated to prolong life.
  • PCI with placement of drug-eluting stent(s) should be considered if the patient has:
  • CABG (especially if an IMA can be used) should be considered if the patient has:

Anticipated Outcomes

Resolution of both symptomatic and asymptomatic ischemia.

Other Concerns

If a patient had angina or ischemia despite optimal medical management, revascularization should be considered. Also, if a patient has angina after having CABG, PCI with placement of drug-eluting stent(s) should be considered. Furthermore, if a patient fails PCI, either through initial technical failure or repeated episodes of restenosis, they should be considered for CABG– especially if an IMA can be used.

References

  1. ↑ Grube E, Silber S, Hauptmann KE, Mueller R, Buellesfeld L, Gerckens U et al. (2003) TAXUS I: six- and twelve-month results from a randomized, double-blind trial on a slow-release paclitaxel-eluting stent for de novo coronary lesions. Circulation 107 (1):38-42. PMID: 12515740
  2. ↑ Holmes DR, Leon MB, Moses JW, Popma JJ, Cutlip D, Fitzgerald PJ et al. (2004) Analysis of 1-year clinical outcomes in the SIRIUS trial: a randomized trial of a sirolimus-eluting stent versus a standard stent in patients at high risk for coronary restenosis. Circulation 109 (5):634-40. DOI:10.1161/01.CIR.0000112572.57794.22 PMID: 14769686
  3. ↑ Baumgart D, Klauss V, Baer F, Hartmann F, Drexler H, Motz W et al. (2007) One-year results of the SCORPIUS study: a German multicenter investigation on the effectiveness of sirolimus-eluting stents in diabetic patients. J Am Coll Cardiol 50 (17):1627-34. DOI:10.1016/j.jacc.2007.07.035 PMID: 17950142
  4. ↑ Galløe AM, Thuesen L, Kelbaek H, Thayssen P, Rasmussen K, Hansen PR et al. (2008) Comparison of paclitaxel- and sirolimus-eluting stents in everyday clinical practice: the SORT OUT II randomized trial. JAMA 299 (4):409-16. DOI:10.1001/jama.299.4.409 PMID: 18230778


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