Temporal changes in the outcomes of patients with diabetes mellitus undergoing percutaneous coronary intervention in the National Heart, Lung, and Blood Institute dynamic registry

Evolution of drug-eluting coronary stents: a back-and-forth journey from the bench-to-bedside

Coronary stents have revolutionized the treatment of coronary artery disease. Compared with balloon angioplasty, bare-metal stents effectively prevented abrupt vessel closure but were limited by in-stent restenosis due to smooth muscle cell proliferation and neointimal hyperplasia. The first-generation drug-eluting stent (DES), with its antiproliferative drug coating, offered substantial advantages over bare-metal stents as it mitigated the risk of in-stent restenosis. Nonetheless, they had several design limitations that increased the risk of late stent thrombosis. Significant advances in stent design, including thinner struts, enhanced polymers' formulation, and more potent antiproliferative agents, have led to the introduction of new-generation DES with a superior safety profile. Cardiologists have over 20 different DES types to choose from, each with its unique features and characteristics. This review highlights the evolution of stent design and summarizes the clinical data on the different stent types. We conclude by discussing the clinical implications of stent design in high-risk subsets of patients.

Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention in Patients With Diabetes

As percutaneous coronary intervention (PCI) continues to evolve, comparative outcomes for PCI vs coronary artery bypass grafting (CABG) remain relevant in diabetic patients. All revascularization procedures in patients with coronary artery disease and diabetes mellitus from 2010 to 2018 were included. Propensity matching was used to identify equivalent cohorts to compare revascularization strategies. Primary outcomes included 30-day, 1-year, and 5-year mortality. Multivariable analysis was used to define factors associated with major adverse cardiovascular and cerebrovascular events (MACCE). A total of 2869 patients with diabetes were divided into PCI (n = 653) and CABG (n = 2216) cohorts. Propensity matching yielded a 1:1 match consisting of 552 patients in each cohort (CABG vs PCI). Total median follow-up was 3.28 years (range: 1.83-5.00). Following propensity matching in patients with no prior PCI (1:1; n = 279), mortality remained significantly higher in the PCI cohort at 1 year (13.98% vs 7.53%; P = 0.014) and 5 years (26.88% vs 16.85%; P < 0.004). Hospital readmissions were higher for PCI patients at 1 year (16.49% vs 9.32%; P < 0.0122) and 5 years (19.71% vs 11.83%; P = 0.011). MACCE occurred more frequently in the PCI cohort (32.97% vs 21.51%; P = 0.002). Need for subsequent revascularization (6.45% vs 2.51%; P = 0.024) were significantly higher in the PCI cohort, and time interval to revascularization was significantly longer in the CABG cohort (3.48 [2.11-5.17] vs 2.62 [1.33-4.25] years; P < 0.001). The current study reports improved survival, fewer long-term hospital readmissions, and reduced MACCE and need for repeat revascularization in the CABG cohort. Given these data, patients with diabetes mellitus and coronary artery disease may fare better with surgical revascularization, compared to PCI.

Coronary artery disease in black African patients with diabetes: Insights from an Ivorian cardiac catheterization centre

BACKGROUND

Coronary angiography data are scarce for black patients with diabetes.

AIM

To assess coronary angiography findings in patients with diabetes at the Abidjan Heart Institute.

METHODS

This observational cross-sectional survey was conducted between 1 April 2010 and 31 December 2014. All patients admitted for known or suspected coronary artery disease who underwent coronary angiography were included in the Registre Prospectif des Actes de Cardiologie Interventionnelle de l'Institut de Cardiologie d'Abidjan. We analysed and compared coronary angiographical findings in patients with and without diabetes.

RESULTS

Eighty patients with diabetes were compared with 353 patients without diabetes. Patients with diabetes were significantly older (58.7±8.9 vs 52.1±11.5 years; P<0.001). Hypertension and hypertriglyceridaemia were significantly associated with diabetes (P<0.001 and P=0.04, respectively). A higher proportion of patients with diabetes had an abnormal coronary angiogram (85.0% vs 67.7%; P=0.002). Coronary artery disease in patients with diabetes was predominantly characterized by multivessel disease (P<0.001). Cardiovascular risk factors associated with diabetes influenced the severity of coronary lesions. A SYNTAX score≥33 was found in a higher proportion of patients with diabetes (12.5% vs 7.1%). In the multivariable logistic regression, after adjustment, age>60 years (hazard ratio 2.53, 95% confidence interval 1.59-4.04; P<0.001) and diabetes (hazard ratio 2.12, 95% confidence interval 1.26-3.57; P=0.004) were associated with multivessel coronary artery disease.

CONCLUSIONS

In our study, diabetes emerged as a risk factor for multivessel coronary artery disease. Future studies should help to define the long-term prognosis of these patients, and to assess the benefits of myocardial revascularization procedures.

The Potential Effects of New Stent Platforms for Coronary Revascularization in Patients With Diabetes

Coronary artery disease in patients with diabetes mellitus (DM) is characterized by extensive atherosclerosis, longer lesions, and diffuse distal disease. Consequently, these patients have worse outcomes after coronary revascularization, regardless of the modality used. Traditionally, coronary artery bypass grafting (CABG) has been regarded as more effective than percutaneous coronary intervention (PCI) in patients with DM, likely because of more complete revascularization and protection against disease progression in the bypass segment. Revascularization with balloon angioplasty, bare-metal stents, and first-generation drug-eluting stents have all been shown to be inferior to CABG in patients with DM. Current professional society guidelines reflect these findings, strongly recommending CABG over PCI in this setting. Newer stent platforms, however, have challenged this notion. The use of thinner struts, biocompatible polymer coating, and newer antiproliferative agents have improved the rates of cardiovascular events in patients with DM revascularized percutaneously. Since the publication of current guidelines, new studies suggested acceptable outcomes in patients with DM revascularized with second-generation drug-eluting stents, even though these conclusions are drawn from small subgroup analyses or nonrandomized studies. Robust registry data suggest similar mortality with lower rates of stroke after PCI compared with surgery, at the expense of increased rates of repeat revascularization. If complete revascularization can be achieved, similar rates of myocardial infarction are also observed. Therefore, contemporary revascularization in patients with DM with multivessel coronary artery disease should involve a multidisciplinary approach, in which interventional cardiologists and cardiac surgeons involve their patients to individualize treatment choices, and balance the risks and effectiveness of each modality.

Relationship between diabetes and ischaemic injury among patients with revascularized ST-elevation myocardial infarction

AIMS

Studies comparing reperfusion efficacy and myocardial damage between diabetic and non-diabetic patients with ST-elevation myocardial infarction (STEMI) are scarce and have reported conflicting results. The aim was to investigate the impact of preadmission diabetic status on myocardial salvage and damage as determined by cardiac magnetic resonance (CMR), and to evaluate its prognostic relevance.

MATERIALS AND METHODS

We enrolled 792 patients with STEMI at 8 sites. CMR core laboratory analysis was performed to determine infarct characteristics. Major adverse cardiac events (MACE), defined as a composite of all-cause death, non-fatal re-infarction and new congestive heart failure, were recorded at 12 months. Patients were categorized according to preexisting diabetes mellitus (DM), and according to insulin-treated DM (ITDM) and non-insulin-treated DM (NITDM).

RESULTS

One-hundred and sixty (20%) patients had DM and 74 (9%) were insulin-treated. There was no difference in the myocardial salvage index, infarct size, microvascular obstruction and left ventricular ejection fraction between all patient groups (all P > .05). Patients with DM were at higher risk of MACE (11% vs 6%, P = .03) than non-DM patients. After stratification according to preadmission anti-diabetic therapy, MACE rate was comparable between NITDM and non-DM (P > .05), whereas the group of ITDM patients had significantly worse outcome (P < .001).

CONCLUSIONS

Diabetic patients with STEMI, especially those having ITDM, had an increased risk of MACE. The adverse clinical outcome was, however, not explained by an impact of DM on reperfusion success or myocardial damage. Clinical trial registry number: NCT00712101.

Clinical Outcomes in Diabetic Patients Who Underwent Percutaneous Coronary Intervention during the Plain Old Balloon Angioplasty (POBA)-, Bare Metal Stents (BMS)- and Drug-eluting Stents (DES)-eras from 1984 to 2010

Objective Diabetes is a negative predictor in coronary artery disease patients. Since the introduction of percutaneous coronary intervention (PCI), PCI has evolved through technological advances in devices, improvements in operators' techniques and the establishment of effective therapeutic protocols. The aim of this study is to examine the changes in the clinical outcomes following PCI in patients with diabetes. Methods We compared the clinical outcomes in patients with diabetes following PCI from 1984 to 2010 at Juntendo University over three eras (plain old balloon angioplasty (POBA)-, bare metal stents (BMS)- and drug-eluting stents (DES)-eras). The primary endpoint was a composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke and repeat revascularization within 3 years after the index PCI. Results A total of 1,584 patients were examined. The baseline characteristics became unfavorable over time with regard to age, prevalence of hypertension, presentation with acute coronary syndrome and a reduced left ventricular ejection fraction. The administration of aspirin, statins and -blockers increased over time. The event-free survival rate for the 3-year cardiovascular events was lower in the DES-era. The adjusted relative risk reduction for 3-year cardiovascular events was 46 % in the DES-era compared with the POBA-era. Conclusion The incidence of 3-year cardiovascular events decreased from 1984 to 2010 in patients with diabetes following PCI, despite the higher risk profiles in the DES-era.

Outcomes of DES in Diabetic and Nondiabetic Patients with Complex Coronary Artery Disease after Risk Stratification by the SYNTAX Score

Diabetes mellitus (DM) increases the risk of adverse outcomes after coronary revascularization. Controversy persists regarding the optimal revascularization strategy for diabetic patients with multivessel coronary artery disease (MVD).

Comparison between diabetic and non-diabetic patients after successful percutaneous coronary intervention for chronic total occlusions in the drug-eluting stent era

OBJECTIVE

Diabetes mellitus and chronic total occlusions are associated with unfavorable outcome after percutaneous coronary intervention. We sought to assess the clinical and angiographic outcomes of diabetic and non-diabetic patients who underwent successful percutaneous revascularization of chronic total occlusions with drug-eluting stents.

METHODS

Baseline clinical and angiographic characteristics, procedural details, nine-month angiographic follow-up and clinical events at 12 months were compared between 75 diabetic and 132 non-diabetic patients included in a clinical trial that randomized successful recanalization of chronic total occlusions to receive sirolimus- or everolimus-eluting stents.

RESULTS

In both diabetic and non-diabetic groups there was a favorable non-significantly different angiographic result at nine months, with low in-stent late loss (0.14±0.60 mm vs. 0.25±0.68 mm, p=0.305) and rates of binary restenosis (4.0% vs. 10.6%, p=0.180) and reocclusion (0.0% vs. 2.3%, p=0.334). During follow-up similar survival from death (97.3±1.9% vs. 99.2±0.8%, log-rank p=0.273), acute myocardial infarction (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192), target vessel revascularization (88.7±3.8% vs. 88.2±2.9%, log-rank p=0.899) and stent thrombosis (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192) was observed. Furthermore, the presence of more diffuse peripheral and coronary artery disease and higher frequency of calcified lesions in diabetic patients did not lead to significant differences in the approach (20.0% vs. 25.0% radial approach, p=0.413), strategy (6.7% vs. 3.8% retrograde strategy, p=0.353), total stent length (48.1±24.6 mm vs. 49.2±23.9 mm, p=0758) or contrast volume (261.3±116.4 ml vs. 297.4±135.9 ml, p=0.109) required for revascularization.

CONCLUSIONS

In the drug-eluting stent era, diabetic and non-diabetic patients have comparable favorable clinical and angiographic outcomes after successful percutaneous revascularization of chronic total occlusions.

National trends in utilization and outcomes of coronary revascularization procedures among people with and without type 2 diabetes in Spain (2001-2011)

BACKGROUND

Diabetes is associated with a high risk of death due to coronary artery disease (CAD). People with diabetes suffering from CAD are frequently treated with revascularization procedures. We aim to compare trends in the use and outcomes of coronary revascularization procedures in diabetic and non-diabetic patients in Spain between 2001 and 2011.

METHODS

We identified all patients who had undergone coronary revascularization procedures, percutaneous coronary interventions (PCI) and coronary artery bypass graft (CABG) surgeries, using national hospital discharge data. Discharges were grouped by diabetes status: type 2 diabetes and no diabetes. The incidence of discharges attributed to coronary revascularization procedures were calculated stratified by diabetes status. We calculated length of stay and in-hospital mortality (IHM). We apply joinpoint log-linear regression to identify the years in which changes in tendency occurred in the use of PCI and CABG in diabetic and non-diabetic patients. Multivariate analysis was adjusted by age, sex, year and comorbidity (Charlson comorbidity index).

RESULTS

From 2001 to 2011, 434,108 PCIs and 79,986 CABGs were performed. According to the results of the joinpoint analysis, we found that sex and age-adjusted use of PCI increased by 31.4% per year from 2001 to 2003, by 15.9% per year from 2003 to 2006 and by 3.8% per year from 2006 to 2011 in patients with diabetes. IHM among patients with diabetes who underwent a PCI did not change significantly over the entire study period (OR 0.99; 95% CI 0.97-1.00).Among patients with diabetes who underwent a CABG, the sex and age-adjusted CABG incidence rate increased by 10.4% per year from 2001 to 2003, and then decreased by 1.1% through 2011. Diabetic patients who underwent a CABG had a 0.67 (95% CI 0.63-0.71) times lower probability of dying during hospitalization than those without diabetes.

CONCLUSIONS

The annual percent change in PCI procedures increased in diabetic and non-diabetic patients. Higher comorbidity and the female gender are associated with a higher IHM in PCI procedures. In diabetic and non-diabetic patients, we found a decrease in the use of CABG procedures. IHM was higher in patients without diabetes than in those with diabetes.

Clinical outcomes with Biolimus (A9)™ eluting stent, 'BioMatrix' in diabetic patients--interim results from multicenter post market surveillance registry in India

OBJECTIVE

The objective of this registry is to establish safety and efficacy of BioMatrix, BioMatrix™-Biolimus A9™ eluting stent in diabetic population in India.

BACKGROUND

Diabetes mellitus is a major predisposing factor for coronary artery disease. Prognosis for diabetic population patients presenting with coronary artery disease who undergo coronary revascularization is inferior to non diabetics and remains an independent risk factor of restenosis, need for revascularization, and overall mortality. Stent thrombosis is a potential complication of first generation, permanent polymer drug-eluting stents. Biodegradable polymer is a good relief in this era and its utility in diabetic patients will be a major advantage for them.

METHODS

334 patients with diabetes mellitus and requiring angioplasty, implanted with BioMatrix stent were followed at 1, 6, 12 and 24 months who entered in a multicenter registry in India. We analyzed the incidence of major adverse cardiac events (MACE) and stent thrombosis (ST) at 1, 6, 12 and 24 months.

RESULTS

The mean age was 58.71 ± 9.2 years, 81% were males, comorbidity index was 1.6 ± 1.02, and 59.1% presented with acute coronary syndrome. The incidence of adverse event rates was: MACE 1.27%. There were no incidences of myocardial infarction (MI) and target vessel revascularization (TVR). Definite stent thrombosis occurred only in 2 patients.

CONCLUSION

In this registry of diabetic population treated with BioMatrixTM-Biolimus A9TM eluting stent (BioMatrix), the reported incidence of MACE and ST were much lower than previously published results. The 1- and 2-year follow-up result supports favorable clinical outcomes of using BioMatrix stents as a suitable alternative to contemporary DES available during PCI in diabetic patients.

Ongoing treatment with non-steroidal anti-inflammatory drugs at time of admission is associated with poorer prognosis in patients with first-time acute myocardial infarction

BACKGROUND

Use of non-steroidal anti-inflammatory drugs (NSAIDs) has been associated with increased cardiovascular morbidity and mortality. The purpose of this study was to examine the effect of ongoing NSAID treatment at time of admission for myocardial infarction (MI) on prognosis.

METHODS

All patients admitted with first-time MI in 1997-2006 were included by use of individual-level linkage of nationwide registries. By claimed prescription of NSAIDs, availability of tablets was estimated within 14 days prior to inclusion and defined ongoing use. Risk of death within 30 days and risk of death or MI within 1 year was analyzed by logistic regression and Cox proportional-hazard models, respectively.

RESULTS

A total of 97,458 patients were included (mean age 69.9 [SD 13.2] years and 62% males); the 30 day and 1 year mortality rates were 18.1% and 27.7%, respectively. Ongoing NSAID treatment was identified in 12,156 (12.5%) patients and 30-day mortality was significantly increased in patients receiving rofecoxib (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.22-1.68) and celecoxib (OR 1.23; CI 1.03-1.47) relative to no use of NSAIDs. Correspondingly, the 1-year rate of death or recurrent MI was significantly increased in patients receiving rofecoxib (hazard ratio [HR] 1.15; CI 1.04-1.27), celecoxib (HR 1.13; CI 1.01-1.26), diclofenac (HR 1.12; CI 1.04-1.20) or any NSAID use (HR 1.05; CI 1.02-1.09). No association was found for naproxen or ibuprofen.

CONCLUSION

Ongoing treatment with NSAIDs and in particular the cyclooxygenase-2-selective inhibitors rofecoxib, celecoxib, and diclofenac is associated with worsened prognosis in patients admitted with first-time MI.

Glycemic variability and glycemic control in the acutely ill cardiac patient

The mechanisms for hyperglycemia-mediated harm in the hospitalized cardiac patient are poorly understood. Potential obstacles in the inpatient management of hyperglycemia in cardiac patients include rapidly changing clinical status, frequent procedures and interruptions in carbohydrate exposure, and short hospital length of stay. A patient's preadmission regimen is rarely suitable for inpatient glycemic control. Instead, an approach to a flexible, physiologic insulin regimen is described, which is intended to minimize glycemic excursions. When diabetes or hyperglycemia is addressed early and consistently, the hospital stay can serve as a potential window of opportunity for reinforcing self-care behaviors that reduce long-term complications.

Percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in the treatment of diabetic patients with multi-vessel coronary disease: a meta-analysis

Diabetes is prevalent in patients with coronary artery disease. In diabetic patients with multi-vessel coronary disease, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are widely used for revascularization. We aimed to compare the effectiveness and safety of PCI and CABG in these patients. Nine randomized controlled trials were identified in which a total of 1047 diabetic patients were randomly assigned to PCI and 1054 to CABG. Results showed that five-year mortality was significantly higher in diabetic patients after PCI than after CABG (risk difference (RD) of 7%; P<0.001); repeated revascularization was more common after PCI than after CABG (one-year RD of 13%; P<0.001); major adverse cardiac and cerebrovascular events were also more frequent after PCI (one-year RD of 12%; P<0.001); however, the cerebrovascular accident rate was lower in the PCI group than the CABG group (one-year RD of -2%; P=0.004). Conclusively, in diabetic patients with multi-vessel coronary disease, CABG was not only more effective than PCI in reducing mortality but also led to fewer repeated revascularizations and fewer major adverse cardiac and cerebrovascular events. Despite these benefits, CABG did put diabetic patients at higher risk for cerebrovascular accident than PCI.