Coronary artery disease treatment in diabetics: Difference between revisions
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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]] <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]]. | ||
==Percutaneous Revascularization== | '''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 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 nondiabetic patients. This is thought to be secondary to progression of disease in untreated areas and [[restenosis]] in treated areas. | ||
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[[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. | [[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. | ||
==Surgical Revascularization== | '''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 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 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. | ||
'''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. | |||
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Revision as of 14:27, 3 August 2010
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief: Felipe Chaparro, M.D.; David M. Leder, M.D.; Brian C. Bigelow, M.D.
Background
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 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.
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 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
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.
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 nondiabetic patients. This is thought to be secondary to progression of disease in untreated areas and restenosis in treated areas.
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 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.
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 nondiabetic patients. Outcomes with 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.
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.