Long-term angiographic follow-up of coronary balloon angioplasty in patients with diabetes mellitus: a clue to the explanation of the results of the BARI study. Balloon Angioplasty Revascularization Investigation

Propensity-matched analysis of long-term clinical results after ostial circumflex revascularisation

BACKGROUND

Percutaneous coronary intervention (PCI) of the ostium of the left circumflex artery (LCx) is technically challenging. The aim of this study was to compare long-term clinical outcomes of ostial PCI located in the LCx versus the left anterior descending artery (LAD) in a propensity-matched population.

METHODS

Consecutive patients with a symptomatic isolated 'de novo' ostial lesion of the LCx or LAD treated with PCI were included. Patients with a stenosis of >40% in the left main (LM) were excluded. A propensity score matching was performed to compare both groups. The primary endpoint was target lesion revascularisation (TLR); other endpoints included target lesion failure and an analysis of the bifurcation angles.

RESULTS

From 2004 to 2018, 287 consecutive patients with LAD (n=240) or LCx (n=47) ostial lesions treated with PCI were analysed. After the adjustment, 47 matched pairs were obtained. The mean age was 72±12 years and 82% were male. The LM-LAD angle was significantly wider than the LM-LCx angle (128°±23° vs 108°±24°, p=0.002). At a median follow-up of 5.5 (IQR 1.5-9.3) years, the rate of TLR was significantly higher in the LCx group (15% vs 2%); with an HR of 7.5, 95% CI 2.1 to 26.4, p<0.001. Interestingly, in the LCx group, TLR-LM occurred in 43% of the TLR cases; meanwhile, no TLR-LM involvement was found in the LAD group.

CONCLUSIONS

Isolated ostial LCx PCI was associated with an increase in the rate of TLR compared with ostial LAD PCI at long-term follow-up. Larger studies evaluating the optimal percutaneous approach at this location are needed.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY GUIDELINES FOR MANAGEMENT OF DYSLIPIDEMIA AND PREVENTION OF CARDIOVASCULAR DISEASE

OBJECTIVE

The development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs).

METHODS

Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols.

RESULTS

The Executive Summary of this document contains 87 recommendations of which 45 are Grade A (51.7%), 18 are Grade B (20.7%), 15 are Grade C (17.2%), and 9 (10.3%) are Grade D. These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world medical care. The evidence base presented in the subsequent Appendix provides relevant supporting information for Executive Summary Recommendations. This update contains 695 citations of which 203 (29.2 %) are EL 1 (strong), 137 (19.7%) are EL 2 (intermediate), 119 (17.1%) are EL 3 (weak), and 236 (34.0%) are EL 4 (no clinical evidence).

CONCLUSION

This CPG is a practical tool that endocrinologists, other health care professionals, health-related organizations, and regulatory bodies can use to reduce the risks and consequences of dyslipidemia. It provides guidance on screening, risk assessment, and treatment recommendations for a range of individuals with various lipid disorders. The recommendations emphasize the importance of treating low-density lipoprotein cholesterol (LDL-C) in some individuals to lower goals than previously endorsed and support the measurement of coronary artery calcium scores and inflammatory markers to help stratify risk. Special consideration is given to individuals with diabetes, familial hypercholesterolemia, women, and youth with dyslipidemia. Both clinical and cost-effectiveness data are provided to support treatment decisions.

ABBREVIATIONS

4S = Scandinavian Simvastatin Survival Study A1C = glycated hemoglobin AACE = American Association of Clinical Endocrinologists AAP = American Academy of Pediatrics ACC = American College of Cardiology ACE = American College of Endocrinology ACS = acute coronary syndrome ADMIT = Arterial Disease Multiple Intervention Trial ADVENT = Assessment of Diabetes Control and Evaluation of the Efficacy of Niaspan Trial AFCAPS/TexCAPS = Air Force/Texas Coronary Atherosclerosis Prevention Study AHA = American Heart Association AHRQ = Agency for Healthcare Research and Quality AIM-HIGH = Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides trial ASCVD = atherosclerotic cardiovascular disease ATP = Adult Treatment Panel apo = apolipoprotein BEL = best evidence level BIP = Bezafibrate Infarction Prevention trial BMI = body mass index CABG = coronary artery bypass graft CAC = coronary artery calcification CARDS = Collaborative Atorvastatin Diabetes Study CDP = Coronary Drug Project trial CI = confidence interval CIMT = carotid intimal media thickness CKD = chronic kidney disease CPG(s) = clinical practice guideline(s) CRP = C-reactive protein CTT = Cholesterol Treatment Trialists CV = cerebrovascular CVA = cerebrovascular accident EL = evidence level FH = familial hypercholesterolemia FIELD = Secondary Endpoints from the Fenofibrate Intervention and Event Lowering in Diabetes trial FOURIER = Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects With Elevated Risk trial HATS = HDL-Atherosclerosis Treatment Study HDL-C = high-density lipoprotein cholesterol HeFH = heterozygous familial hypercholesterolemia HHS = Helsinki Heart Study HIV = human immunodeficiency virus HoFH = homozygous familial hypercholesterolemia HPS = Heart Protection Study HPS2-THRIVE = Treatment of HDL to Reduce the Incidence of Vascular Events trial HR = hazard ratio HRT = hormone replacement therapy hsCRP = high-sensitivity CRP IMPROVE-IT = Improved Reduction of Outcomes: Vytorin Efficacy International Trial IRAS = Insulin Resistance Atherosclerosis Study JUPITER = Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin LDL-C = low-density lipoprotein cholesterol Lp-PLA2 = lipoprotein-associated phospholipase A2 MACE = major cardiovascular events MESA = Multi-Ethnic Study of Atherosclerosis MetS = metabolic syndrome MI = myocardial infarction MRFIT = Multiple Risk Factor Intervention Trial NCEP = National Cholesterol Education Program NHLBI = National Heart, Lung, and Blood Institute PCOS = polycystic ovary syndrome PCSK9 = proprotein convertase subtilisin/kexin type 9 Post CABG = Post Coronary Artery Bypass Graft trial PROSPER = Prospective Study of Pravastatin in the Elderly at Risk trial QALY = quality-adjusted life-year ROC = receiver-operator characteristic SOC = standard of care SHARP = Study of Heart and Renal Protection T1DM = type 1 diabetes mellitus T2DM = type 2 diabetes mellitus TG = triglycerides TNT = Treating to New Targets trial VA-HIT = Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial VLDL-C = very low-density lipoprotein cholesterol WHI = Women's Health Initiative.

Factors Associated With Coronary Artery Disease Progression Assessed By Serial Coronary Computed Tomography Angiography

Background

Coronary computed tomography angiography (CCTA) allows for noninvasive coronary artery disease (CAD) phenotyping. Factors related to CAD progression are epidemiologically valuable.

Objective

To identify factors associated with CAD progression in patients undergoing sequential CCTA testing.

Methods

We retrospectively analyzed 384 consecutive patients who had at least two CCTA studies between December 2005 and March 2013. Due to limitations in the quantification of CAD progression, we excluded patients who had undergone surgical revascularization previously or percutaneous coronary intervention (PCI) between studies. CAD progression was defined as any increase in the adapted segment stenosis score (calculated using the number of diseased segments and stenosis severity) in all coronary segments without stent (in-stent restenosis was excluded from the analysis). Stepwise logistic regression was used to assess variables associated with CAD progression.

Results

From a final population of 234 patients, a total of 117 (50%) had CAD progression. In a model accounting for major CAD risk factors and other baseline characteristics, only age (odds ratio [OR] 1.04, 95% confidence interval [95%CI] 1.01-1.07), interstudy interval (OR 1.03, 95%CI 1.01-1.04), and past PCI (OR 3.66, 95%CI 1.77-7.55) showed an independent relationship with CAD progression.

Conclusions

A history of PCI with stent placement was independently associated with a 3.7-fold increase in the odds of CAD progression, excluding in-stent restenosis. Age and interstudy interval were also independent predictors of progression.

Association of inflammatory markers and poor outcome in diabetic patients presenting with ST segment elevation myocardial infarction

OBJECTIVE

Carbohydrate metabolism disorders (CMD) significantly impact the development and progression of all forms of ischemic heart disease, and inflammation is regarded as a general pathogenetic link between CMD and ischemic heart disease.

METHODS

A total of 601 patients with ST segment elevation myocardial infarction (MI) (STEMI), admitted within 24 hours from the onset of symptoms during 1 year, were included in this registry study. The blood levels of inflammation markers were measured at days 10-14 with further follow up at 1 year.

RESULTS

The analysis of acute-phase percutaneous coronary intervention impact on the 1-year outcomes showed that endovascular revascularization significantly improved the 1-year prognosis of STEMI patients both with and without CMD. The analysis of inflammation markers showed significantly higher levels of interleukin (IL)-6 and sCD40L in MI patients with diabetes mellitus, and impaired glucose tolerance. Additionally, the patients with impaired glucose tolerance had significantly higher IL-12 levels. In the diabetic MI patients, the odds ratio of a poor 1-year outcome was high for patients with a high Killip classification of acute heart failure upon admission.

CONCLUSION

Persistent inflammation in STEMI patients with CMD undergoing percutaneous coronary intervention might be responsible for vascular complications within 1 year after MI. Comorbid diabetes mellitus or impaired glucose tolerance can amplify the significance of the inflammatory response for the development of adverse 1-year outcomes.

Sirolimus-eluting stent versus bare metal stent in diabetic patients: the final five-year follow-up of the DIABETES trial

AIMS

The DIABETES (DIABETes and sirolimus-Eluting Stent) trial is a prospective, multicentre, randomised, controlled trial aimed at demonstrating the efficacy of sirolimus-eluting stent (SES) as compared to bare metal stent (BMS) implantation in diabetic patients. The aim of the present analysis was to assess the five-year clinical follow-up of the patients included in this trial.

METHODS AND RESULTS

One hundred and sixty patients (222 lesions) were included: 80 patients were randomised to SES and 80 patients to BMS. Patients were eligible for the study if they were identified as non-insulin-dependent diabetics (NIDDM) or insulin-dependent diabetics (IDDM), with significant native coronary stenoses in ≥1 vessel. There was a sub-randomisation according to diabetes status. Clinical follow-up was extended up to five years. Five-year clinical follow-up was obtained in 96.2%. Overall, MACE at five years was significantly lower in the SES group as compared with the BMS arm, mainly due to a significant reduction in TLR. There were no significant differences in cardiac death or myocardial infarction (MI). This was also observed in both prespecified subgroups IDDM and NIDDM. In the SES group, the incidence density of definite/probable stent thrombosis was 0.53 per 100 person-years, whereas in the BMS group it was 0.8 per 100 person-years. Independent predictors of MACE were: SES implantation (p<0.001), multivessel stent implantation (p=0.04), and creatinine levels (p=0.001).

CONCLUSIONS

Five-year follow-up of the DIABETES trial suggests the effect of SES in reducing TLR is similar in both IDDM and NIDDM. No major safety concerns in terms of ST, MI or mortality were observed.

Role of surgical revascularization in diabetic patients with coronary artery disease

Diabetes is a well-known risk factor for morbidity and mortality associated with coronary artery disease. Currently, diabetics represent approximately a quarter of patients requiring coronary revascularization in the USA. The purpose of this article is to review and analyze the available data in surgical revascularization of diabetic patients with coronary artery disease. The review will also examine new developments in myocardial revascularization and assess their probable impact on the long-term outcome of diabetic patients.

Impact of diabetes on 10-year outcomes of patients with multivessel coronary artery disease in the Medicine, Angioplasty, or Surgery Study II (MASS II) trial

INTRODUCTION

Diabetes mellitus is a major cause of coronary artery disease (CAD). Despite improvement in the management of patients with stable CAD, diabetes remains a major cause of increased morbidity and mortality. There is no conclusive evidence that either modality is better than medical therapy alone for the treatment of stable multivessel CAD in patients with diabetes in a very long-term follow-up. Our aim was to compare 3 therapeutic strategies for stable multivessel CAD in a diabetic population and non-diabetic population.

METHODS

It was compared medical therapy (MT), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in 232 diabetic patients and 379 nondiabetic patients with multivessel CAD. Endpoints evaluated were overall and cardiac mortality.

RESULTS

Patients (n = 611) were randomized to CABG (n = 203), PCI (n = 205), or MT (n = 203). In a 10-year follow-up, more deaths occurred among patients with diabetes than among patients without diabetes (P = .001) for overall mortality. In this follow-up, 10-year mortality rates were 32.3% and 23.2% for diabetics and non-diabetics respectively (P = .024). Regarding cardiac mortality, 10-year cardiac mortality rates were 19.4% and 12.7% respectively (P = .031).Considering only diabetic patients and stratifying this population by treatment option, we found mortality rates of 31.3% for PCI, 27.5% for CABG and 37.5% for MT (P = .015 for CABG vs MT) and cardiac mortality rates of 18.8%, 12.5% and 26.1% respectively (P = .005 for CABG vs MT).

CONCLUSIONS/INTERPRETATION

Among patients with stable multivessel CAD and preserved left ventricular ejection fraction, the 3 therapeutic regimens had high rates of overall and cardiac-related deaths among diabetic compared with non-diabetic patients. Moreover, better outcomes were observed in diabetic patients undergoing CABG compared to MT in relation to overall and cardiac mortality in a 10-year follow-up.

MRI lesions after invasive therapy of carotid artery stenosis: a risk-modeling analysis

BACKGROUND

Diffusion-weighted imaging (DWI) abnormalities can frequently be detected after carotid endarterectomy (CEA) and carotid angioplasty with stent placement (CAS) of the carotid arteries. We looked for possible predictors for the development of DWI lesions during the intervention.

METHODS

We investigated 41 patients who underwent CAS without protection devices and 93 patients who underwent CEA. DWI studies were performed 1 day before and after the intervention.

RESULTS

Ischemic complications consisted of two strokes (2.2%) in the CEA group and one stroke (2.4%) in the CAS group. DWI lesions were detected in 28.0% of all patients after intervention. Using a multivariate regression analysis, diabetes mellitus (DM), hyperlipidemia, symptomatic stenosis, age and CAS were found to be significant predictors for the occurrence of DWI lesions.

CONCLUSIONS

DWI is an objective and highly sensitive method for monitoring interventions of the carotid arteries. Our results point to an increased risk of patients with diabetes and hyperlipidemia to develop DWI lesions during invasive therapy of the ICA.

Percutaneous Coronary Intervention in Patients with Diabetes and Multivessel or Left Main Disease—A Review

Coronary artery disease in patients with diabetes is frequently a diffuse process with multivessel involvement and is associated with increased risk for myocardial infarction and death. The role of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and multivessel disease who require revascularization has been debated and remains uncertain. The debate has been continued mainly because of the question to what degree an increased risk for in-stent restenosis among patients with diabetes contributes to other late adverse outcomes. This article reviews outcomes from early trials of balloon angioplasty versus CABG through later trials of bare-metal stents versus CABG and more recent data with drug-eluting stents as the comparator. although not all studies have been powered to show statistical significance, the results have been generally consistent with a mortality benefit for caBG versus PCI, despite differential risks for restenosis with the various PCI approaches. The review also considers the impact of mammary artery grafting of the left anterior descending artery and individual case selection on these results, and proposes an algorithm for selection of patients in whom PCI remains a reasonable strategy.

Long-term effect of metabolic syndrome with and without diabetes mellitus on coronary revascularization in Japanese patients undergoing percutaneous coronary intervention

BACKGROUND

Metabolic syndrome (MS) plays a crucial role in the long-term prognosis and primary or secondary prevention of coronary artery disease, regardless of the presence or absence of diabetes mellitus (DM). We previously reported that after percutaneous coronary intervention (PCI), patients with MS had worse long-term outcome. However, there is no evidence indicating the importance of MS with and without DM on re-revascularization procedures in Japanese patients undergoing PCI.

HYPOTHESIS

We hypothesized that MS patients without DM have an increased risk of re-revascularization following PCI.

METHODS

We classified 748 consecutive Japanese patients who had undergone PCI into 4 groups as follows: neither DM nor MS, DM alone, MS alone, and both DM and MS. Post-hoc analyses were conducted using prospectively collected clinical data. Multivariate Cox regression was used to evaluate the risk within each group for subsequent revascularization (repeat PCI and bypass surgery), adjusting for baseline covariates.

RESULTS

The progress of 321 (42.9%) patients without DM or MS, 109 (14.6%) patients with DM alone, 129 (17.2%) patients with MS alone, and 189 (25.3%) patients with both DM and MS was followed up for a mean duration of 12.0 ± 3.6 years. Patients with MS alone (hazard ratio: 1.38, 95% confidence interval: 1.01-1.89, P = 0.04) and those with both DM and MS (hazard ratio: 1.36, 95% confidence interval: 1.02-1.81, P = 0.04) had a significantly increased risk for revascularization.

CONCLUSIONS

The presence of MS significantly increased the risk for subsequent revascularization among Japanese patients who underwent PCI, regardless of the presence or absence of DM.

Trends in postacute myocardial infarction management and mortality in patients with diabetes. A population-based study from 1995 to 2001

OBJECTIVE

To compare trends in coronary revascularization use and case fatality rate (CFR) following acute myocardial infarction in patients with and without diabetes.

METHODS

A retrospective study of 77,552 patients, 20 years of age or older (25% with diabetes), who were hospitalized for a first acute myocardial infarction in the province of Quebec between April 1995 and December 2001 was conducted. Administrative databases were used to identify patients and assess outcomes.

RESULTS

Compared with patients without diabetes, patients with diabetes underwent more coronary artery bypass graft (CABG) surgeries (11.1% versus 8.3%; P<0.0001) but fewer percutaneous coronary interventions (17.1% versus 20.2%; P<0.0001). The use of percutaneous coronary intervention increased substantially over time in both populations, driven mainly by an increase during the index admission (20.6% versus 16.6% per year; P=0.1144 in patients with and without diabetes, respectively). The use of CABG during the index admission increased markedly among patients with diabetes compared with those without (10.3% versus 5.3% per year; P=0.0072); however, at one-year following discharge, CABG use remained stable in patients with diabetes and fell in those without (-0.7% versus -5.3% per year; P=0.2046). Concomitantly, patients with diabetes presented a similar decline in CFR compared with patients without diabetes. The decline was more pronounced during the index admission (-5.0% versus -4.1% per year; P=0.282) than at one-year following discharge (-2.5% versus -2.5% per year; P=0.629) in patients with and without diabetes, respectively. However, fatal outcome remained higher in patients with diabetes than without, with an adjusted RR of 1.21 (95% CI 1.18 to 1.24) at one-year follow-up.

CONCLUSION

Overall, coronary revascularization use and CFR improved over time in patients with diabetes. Nevertheless, the mortality rate in patients with diabetes remains higher than in patients without diabetes, indicating that additional progress is required to improve the poorer prognosis in this population.

MRI plaque imaging reveals high-risk carotid plaques especially in diabetic patients irrespective of the degree of stenosis

Background

Plaque imaging based on magnetic resonance imaging (MRI) represents a new modality for risk assessment in atherosclerosis. It allows classification of carotid plaques in high-risk and low-risk lesion types (I-VIII). Type 2 diabetes mellitus (DM 2) represents a known risk factor for atherosclerosis, but its specific influence on plaque vulnerability is not fully understood. This study investigates whether MRI-plaque imaging can reveal differences in carotid plaque features of diabetic patients compared to nondiabetics.

Methods

191 patients with moderate to high-grade carotid artery stenosis were enrolled after written informed consent was obtained. Each patient underwent MRI-plaque imaging using a 1.5-T scanner with phased-array carotid coils. The carotid plaques were classified as lesion types I-VIII according to the MRI-modified AHA criteria. For 36 patients histology data was available.

Results

Eleven patients were excluded because of insufficient MR-image quality. DM 2 was diagnosed in 51 patients (28.3%). Concordance between histology and MRI-classification was 91.7% (33/36) and showed a Cohen's kappa value of 0.81 with a 95% CI of 0.98-1.15. MRI-defined high-risk lesion types were overrepresented in diabetic patients (n = 29; 56.8%). Multiple logistic regression analysis revealed association between DM 2 and MRI-defined high-risk lesion types (OR 2.59; 95% CI [1.15-5.81]), independent of the degree of stenosis.

Conclusion

DM 2 seems to represent a predictor for the development of vulnerable carotid plaques irrespective of the degree of stenosis and other risk factors. MRI-plaque imaging represents a new tool for risk stratification of diabetic patients.

See Commentary: http://www.biomedcentral.com/1741-7015/8/78/abstract

CCN3 inhibits neointimal hyperplasia through modulation of smooth muscle cell growth and migration

OBJECTIVE

CCN3 belongs to the CCN family, which constitutes multifunctional secreted proteins that act as matrix cellular regulators. We investigated the pathophysiological roles of CCN3 in the vessels.

METHODS AND RESULTS

We examined the effects of CCN3 on the proliferation and migration of rat vascular smooth muscle cells (VSMC). CCN3 knockout mice were created, and vascular phenotypes and neointimal hyperplasia induced by photochemically induced thrombosis were investigated. CCN3 suppressed the VSMC proliferation induced by fetal bovine serum. The neutralizing antibody for transforming growth factor-beta did not affect the growth inhibitory effect of CCN3. Moreover, CCN3 enhanced the mRNA expression of cyclin-dependent kinase inhibitors, p21 and p15. Gamma secretase inhibitor, an inhibitor of Notch signaling, partially inhibited the enhanced expression of p21 induced by CCN3. CCN3 also inhibited the VSMC migration. Finally, the histopathologic evaluation of the arteries 21 days after the endothelial injury revealed a 6-fold enhancement of neointimal thickening in the null mice compared with the wild-type mice.

CONCLUSIONS

CCN3 suppresses neointimal thickening through the inhibition of VSMC migration and proliferation. Our findings indicate the involvement of CCN3 in vascular homeostasis, especially on injury, and the potential usefulness of this molecule in the modulation of atherosclerotic vascular disease.

C-reactive protein predicts non-target lesion revascularization and cardiac events following percutaneous coronary intervention in patients with angina pectoris

BACKGROUND

C-reactive protein (CRP) plays a pivotal role in the pathogenesis of atherosclerosis progression. We hypothesized that CRP might be related to progression of non-target lesion and prognosis in patients with angina pectoris.

METHODS AND RESULTS

We enrolled 111 patients with angina pectoris treated with coronary stenting. CRP was measured before coronary stenting. Patients were grouped according to the CRP value, high CRP group (n=56, ≥ 0.12 mg/dl) and low CRP group (n=55, <0.12 mg/dl). Kaplan-Meier analysis showed that non-target lesion revascularization (TLR) free survival was significantly lower in the high CRP group than in the low CRP group (log-rank, p=0.004). Moreover, cardiac event (death, myocardial infarction, TLR, and non-TLR) free survival was also significantly lower in the high CRP group than in the low CRP group (p=0.004). By univariate and multivariate analysis, CRP was the only independent predictor of non-TLR (odds ratio, 1.26; p<0.001 [95% confidence interval (CI) 0.98-1.64]). Also, CRP was a predictor of the cardiac events (odds ratio, 1.32; p=0.04 [95% CI 1.02-1.72]).

CONCLUSIONS

CRP was a predictor of non-TLR and cardiac events following stenting in patients with angina pectoris.

Restenosis and progression of coronary disease after balloon angioplasty in patients with diabetes mellitus

BACKGROUND

Patients with diabetes mellitus (D) (both insulin-requiring D [IRD] and non-IRD) who undergo angioplasty have worse long-term outcome than do non-D patients. Few data are available in the literature that explain these findings.

HYPOTHESIS

The study was undertaken to compare restenosis and progression of coronary disease after angioplasty in IRD patients, in non-IRD patients, and in non-D patients.

METHODS

Diabetic patients who underwent coronary angioplasty were separated into two subgroups: IRD and non-IRD patients. Their angiographic outcome was compared with non-D patients. We examined retrospectively 353 coronary angiograms of patients who were referred for diagnostic angiography > 1 month after successful angioplasty. Quantitative angiography was used to determine the outcome in dilated narrowings (restenosis) and in nondilated narrowings (disease progression).

RESULTS

Baseline clinical and angiographic characteristics were similar in all groups. Restenosis rate was higher in IRD (61%) than in non-IRD (36%) and non-D (35%) patients (p = 0.04). Late luminal loss after angioplasty was two times greater in IRD patients than in the other two groups (p = 0.01). Disease progression of nondilated narrowings was significantly more prominent in non-IRD than in non-D patients: Diameter stenoses were similar in the initial angiogram, but narrowings were significantly more severe (p = 0.02) in the final angiogram (70 +/- 27% and 60 +/- 33%, respectively). New narrowings were more common in non-IRD than in non-D patients: there was a 23% increase in the number of narrowings in the follow-up angiogram in non-IRD patients compared with only 12% in non-D patients (p < 0.003). These new narrowings were more common (p = 0.01) in angioplasty arteries (57 narrowings on 420 arteries--13.6%) than in nonangioplasty arteries (54 narrowings on 639 arteries--8.5%).

CONCLUSION

Restenosis is more common in IRD patients and explains the high rate of adverse cardiac events within the first year after coronary intervention in these patients (mainly target lesion revascularization). Disease progression (including new narrowings) is the main determinant of patient outcome > 1 year after coronary intervention and is accelerated in non-IRD compared with non-D patients.

RAGE and soluble RAGE: potential therapeutic targets for cardiovascular diseases

Receptor for advanced glycation end-products (RAGE) is known to be involved in microvascular complications in diabetes. RAGE is also profoundly associated with macrovascular complications in diabetes through regulation of atherogenesis, angiogenic response, vascular injury, and inflammatory response. The potential significance of RAGE in the pathogenesis of cardiovascular disease appears not to be confined solely to nondiabetic rather than diabetic conditions. Numerous truncated forms of RAGE have recently been described, and the C-terminally truncated soluble form of RAGE has received much attention. Soluble RAGE consists of several forms, including endogenous secretory RAGE (esRAGE), which is a spliced variant of RAGE, and a shedded form derived from cell-surface RAGE. These heterogeneous forms of soluble RAGE, which carry all of the extracellular domains but are devoid of the transmembrane and intracytoplasmic domains, bind ligands including AGEs and can antagonize RAGE signaling in vitro and in vivo. ELISA systems have been developed to measure plasma esRAGE and total soluble RAGE, and the pathophysiological roles of soluble RAGE have begun to be unveiled clinically. In this review, we summarize recent findings regarding pathophysiological roles in cardiovascular disease of RAGE and soluble RAGE and discuss their potential usefulness as therapeutic targets and biomarkers for the disease.

Outcomes of Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention With Drug-Eluting Stents for Patients With Multivessel Coronary Artery Disease

Background— Advances in coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI) with drug-eluting stents have dramatically improved results of these procedures. The optimal treatment for patients with multivessel coronary artery disease is uncertain given the lack of prospective, randomized data reflecting current practice. This study represents a “real-world” evaluation of current technology in the treatment of multivessel coronary artery disease.

Methods and Results— A total of 1680 patients undergoing revascularization for multivessel coronary artery disease were identified. Of these, 1080 patients were treated for 2-vessel disease (196 CABG and 884 PCI) and 600 for 3-vessel disease (505 CABG and 95 PCI). One-year mortality, cerebrovascular events, Q-wave myocardial infarction, target vessel failure, and composite major adverse cardiovascular and cerebrovascular events were compared between the CABG and PCI cohorts. Outcomes were adjusted for baseline covariates and reported as hazard ratios. The unadjusted major adverse cardiovascular and cerebrovascular event rate was reduced with CABG for patients with 2-vessel disease (9.7% CABG versus 21.2% PCI; P <0.001) and 3-vessel disease (10.8% CABG versus 28.4% PCI; P <0.001). Adjusted outcomes showed increased major adverse cardiovascular and cerebrovascular event with PCI for patients with 2-vessel (hazard ratio 2.29; 95% CI 1.39 to 3.76; P =0.01) and 3-vessel disease (hazard ratio 2.90; 95% CI 1.76 to 4.78; P <0.001). Adjusted outcomes for the nondiabetic subpopulation demonstrated equivalent major adverse cardiovascular and cerebrovascular event with PCI for 2-vessel (hazard ratio 1.77; 95% CI 0.96 to 3.25; P =0.07) and 3-vessel disease (hazard ratio 1.70; 95% CI 0.77 to 3.61; P =0.19).

Conclusions— Compared with PCI with drug-eluting stents, CABG resulted in improved major adverse cardiovascular and cerebrovascular event in patients with 2- and 3-vessel coronary artery disease, primarily in those with underlying diabetes. Coronary artery bypass surgery may be the preferred revascularization strategy in diabetic patients with multivessel coronary artery disease.

Impact of admission hyperglycemia and diabetes mellitus on short- and long-term mortality after acute myocardial infarction in the coronary intervention era

The influence of admission hyperglycemia and diabetes on short- and long-term mortality of patients with acute myocardial infarction (AMI) in the percutaneous coronary intervention (PCI) era was investigated. From 1996 to 2003, a total of 802 consecutive patients with AMI underwent coronary angiography. Primary PCI was performed in 724 patients (90%). Three-year mortality curves were constructed using the Kaplan-Meier method. Cox proportional hazard regression was used to identify independent predictors of 30-day mortality and mortality from 30 days to 3 years. There were 261 patients with admission hyperglycemia (admission glucose>or=11.1 mmol/L) and 212 patients with diabetes. Admission hyperglycemia was associated with a significantly higher 30-day mortality rate (8.4% vs 2.4%, p<0.001). However, there was no significant difference in 30-day mortality rates between diabetic and nondiabetic patients (5.7% vs 3.9%, p=0.29). Conversely, diabetes significantly increased mortality from 30 days to 3 years (10.0% vs 5.5%, p=0.03), but admission hyperglycemia did not (8.4% vs 5.9%, p=0.19). Multivariate analysis showed that hyperglycemia was an independent predictor of 30-day mortality (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.13 to 2.61, p=0.01), but diabetes was not (OR 0.84, 95% CI 0.55 to 1.27, p=0.42). Diabetes was independently associated with mortality from 30 days to 3 years (OR 1.43, 95% CI 1.02 to 1.97, p=0.04), but hyperglycemia had a neutral effect (OR 0.98, 95% CI 0.70 to 1.36, p=0.92). In conclusion, in the PCI era, admission hyperglycemia was associated with short-term mortality, whereas diabetes increased long-term mortality after convalescence in patients with AMI. Admission hyperglycemia and diabetes should be treated as 2 distinct disease states.

Meta-analysis of randomized trials of drug-eluting stents versus bare metal stents in patients with diabetes mellitus

Diabetes mellitus is a major risk factor for restenosis in patients undergoing percutaneous coronary intervention. Randomized controlled trials comparing drug-eluting stents (DESs) with bare metal stents (BMSs) showed a marked decrease in in-stent restenosis and target lesion revascularization with DESs in the total patient population enrolled in the studies, including patients with diabetes. However, it remains unclear whether the antirestenotic benefit of DESs is preserved in the high-risk diabetic subgroup. MEDLINE, EMBASE, ISI Web of Knowledge, Current Contents, International Pharmaceutical Abstracts, and recent Scientific Sessions databases were searched to identify relevant clinical trials comparing DESs with BMSs. A randomized controlled trial was included if it provided outcome data for patients with diabetes for > or =1 of the following: late lumen loss, in-stent restenosis, or target lesion revascularization. Data were combined using fixed-effects models, and standard tests for heterogeneity were performed. Eight studies with 1,520 patients with diabetes were identified that reported > or =1 outcome of interest. Mean late lumen losses (7 studies) were 0.93 mm (95% confidence interval [CI] 0.510 to 1.348) with BMSs and 0.18 mm (95% CI -0.088 to +0.446) with DESs. For patients receiving a DES, this translated into a marked decrease in in-stent restenosis (7 studies, RR 0.14, 95% CI 0.10 to 0.22, p <0.001) and target lesion revascularization (8 studies, RR 0.34, 95% CI 0.26 to 0.45, p <0.001). DES use is associated with a marked decrease in in-stent restenosis and target lesion revascularization in patients with diabetes. In conclusion, the analysis supports the current widespread use of DESs in these high-risk patients.

Preprocedure hyperglycemia is more strongly associated with restenosis in diabetic patients after percutaneous coronary intervention than is hemoglobin A1C

BACKGROUND

Although more frequent in diabetic patients, restenosis after percutaneous coronary intervention (PCI) is less common in those with good glycemic control. High circulating insulin levels may also be associated with more frequent restenosis.

METHODS

Fasting blood samples were obtained from 162 diabetic patients immediately prior to the PCI and analyzed for glucose, hemoglobin A1C, and insulin. Nine-month follow-up information was obtained in 145 (89.5%) patients. Target vessel revascularization (TVR) was the surrogate for restenosis.

RESULTS

Patients were divided into quartiles with regard to their blood levels. Insulin, calculated insulin resistance, and hemoglobin A1C were not associated with increased TVR rates. Glucose level was significantly associated (P=.02). Patients in the two lower quartiles (glucose < or = 128 mg/dl) had a 9-month TVR rate of 12.7% while those in the two higher quartiles (>128 mg/dl) had a rate of 33.8% (P=.005). Level of glucose was independent of hemoglobin A1C. In patients whose A1C level was < or = 7%, the TVR rate was greater in those with a glucose level >128 mg/dl (39.1% vs. 10.6%, P=.009). Similarly, in patients with a hemoglobin A1C level >7%, the TVR rate was lower in patients with a glucose level < or = 128 mg/dl, but this difference did not reach statistical significance (16.6% vs. 31.3%, P=.3).

CONCLUSIONS

Hemoglobin A1C, insulin, and insulin resistance at the time of the PCI are not associated with restenosis. Periprocedural hyperglycemia may promote restenosis in diabetics.

Percutaneous coronary revascularization in diabetics: from balloon angioplasty to drug-eluting stents

Diabetic patients may have aggressive coronary disease with an excessive rate of restenosis and accelerated atherosclerotic progression. This article reviews the different modalities of percutaneous treatment and their results in the diabetic population, from the early days of balloon angioplasty to the current implementation of drug-eluting stents. As restenosis may be virtually eradicated in the near future, plaque progression remains the cornerstone for interventional cardiologists and the medical community. In this regard, attempts to modify life habits, and a more accurate control of the components of the metabolic syndrome should be the main therapeutic objective.

Drug-Eluting Coronary Stents

The introduction and widespread use of coronary stents have been the most important advancement in the percutaneous treatment of coronary artery disease since the introduction of balloon angioplasty. Coronary artery stents reduce the rate of angiographic and clinical restenosis compared to balloon angioplasty. This angiographic restenosis was further reduced with the introduction of drug-eluting stents and hence further reduction in the frequency of major adverse cardiac events. Herein we present a comprehensive and up-to-date review about the use of drug-eluting stents in the treatment of coronary artery disease.

Does diabetes mellitus abolish the beneficial effect of primary coronary angioplasty on long-term risk of reinfarction after acute ST-segment elevation myocardial infarction compared with fibrinolysis? (A DANAMI-2 substudy)

Little is known about the effect of diabetes mellitus on long-term clinical outcome after primary percutaneous coronary intervention (pPCI) compared with fibrinolysis in patients who have acute ST-elevation myocardial infarction. We analyzed 3-year clinical outcome in diabetic patients and nondiabetic patients who had been randomized to fibrinolysis or pPCI in the DANAMI-2 trial to compare long-term clinical outcome. The primary end point was a composite of death, clinical reinfarction, or disabling stroke. Median follow-up was 3.8 years. Among 1,572 consecutive patients who had ST-elevation myocardial infarction and were randomized to pPCI or fibrinolysis, 173 (11.0%) had diabetes mellitus; 60 of these patients received metformin treatment and were excluded. After 3 years no difference was found between diabetic patients who underwent pPCI versus fibrinolysis (combined event p=0.37, reinfarction p=0.06 in favor of fibrinolysis), whereas pPCI was superior to fibrinolysis in nondiabetic patients (combined event p=0.002, clinical reinfarction p<0.001). Three-year incidence of clinical reinfarction analyzed with Cox's regression showed that pPCI compared with fibrinolysis increased the relative risk of clinical reinfarction in diabetic patients (relative risk 2.57, 95% confidence interval 1.48 to 4.46, p <0.001) but decreased the risk in nondiabetic patients (relative risk 0.52, 95% confidence interval 0.36 to 0.74, p<0.001). In conclusion, from the DANAMI-2 trial we hypothesize that diabetes may abolish the beneficial effect of pPCI on long-term risk of clinical reinfarction.

Nature of coronary disease in patients with insulin resistance and its impact on revascularization strategies

Data on the nature of coronary artery disease in patients with insulin resistance and its treatment have been obtained mostly in the diabetic population. The 'quantitative' and 'qualitative' changes in the course of coronary artery disease and the relationship with the increased rate of cardiac events in this population will be discussed. The effects of various methods of revascularization (bypass surgery vs. percutaneous revascularization) and the potential benefit of recent adjuncts to percutaneous revascularization (stents, drug-eluting stents, antiplatelet agents) will be discussed.

Integrated Management of Patients with Diabetes Mellitus and Ischemic Heart Disease: PCI, CABG, and Medical Therapy

Modern coronary revascularization strategies are based on studies performed in the 1970s and 1980s that compared coronary artery bypass surgery with standard medical therapy available at the time. Studies comparing surgical and percutaneous revascularization followed, demonstrating similar long-term outcome among thousands of randomized patients. The largest of these trials, the Bypass Angioplasty Revascularization Investigation (BARI), cast doubt on the generalizability of these findings to all subgroups, finding that patients with diabetes mellitus and multivessel disease had worse long-term outcome with an initial strategy of percutaneous transluminal coronary angioplasty (PTCA). Indeed, patients with diabetes mellitus are at increased risk for cardiovascular morbidity and mortality, while the benefit of standard therapies in these patients is attenuated by the underlying metabolic abnormalities and significant comorbidities associated with the diabetic state. However, surgical and percutaneous revascularization techniques continue to evolve. Similarly, modern medical therapy is markedly superior to that available during these early studies, with demonstrable benefit in primary and secondary prevention of vascular events in both diabetic and nondiabetic patients. Ongoing trials will define the impact of current treatment modalities in this important and growing population.

Impact of treatment of coronary artery disease with sirolimus-eluting stents on outcomes of diabetic and nondiabetic patients

Patients with diabetes mellitus are at increased risk for repeat interventions and mortality after coronary angioplasty and stenting. The efficacy of sirolimus-eluting stents (SESs) to improve the outcomes of these patients is a focus of interest. In the first 1,407 patients treated with SESs at our institution, 492 were diabetic (insulin dependent diabetes mellitus [IDDM], n = 160 and non-insulin-dependent DM [NIDDM], n = 332). The in-hospital and 1- and 6-month clinical outcomes were compared with those of 915 patients without DM (non-DM). The baseline characteristics were similar, except for more women, obesity, previous myocardial infarction, coronary artery bypass grafting, and renal insufficiency in the DM group (p <0.001). Compared with non-DM patients, DM patients had higher in-hospital (p <0.05) and 1-month mortality (p = 0.02). IDDM patients had more in-hospital renal failure (p = 0.04) and Q-wave myocardial infarctions (1.6% vs 0%, p = 0.04) compared with NIDDM patients, and higher mortality (3.1% vs 0.8%, p = 0.04) and subacute stent thromboses (2.3% vs 0.5%, p = 0.07) than non-DM patients at 30 days. At 6 months, DM patients had a higher incidence of Q-wave myocardial infarction, target lesion revascularization-major adverse cardiac events, and composite of death and Q-wave myocardial infarction than non-DM patients (6.0% vs 2.7%, p = 0.01). Late outcomes between the IDDM and NIDDM groups were similar. Multivariate analysis showed diabetes and acute renal failure as independent predictors of target lesion revascularization-major adverse cardiac events. In conclusion, our data showed that, despite a reduction in repeat revascularization, coronary intervention with SESs in diabetic patients is limited by higher mortality at 1 month and a higher incidence of Q-wave myocardial infarction and target lesion revascularization-major adverse cardiac events at 6 months compared with non-DM patients. Careful surveillance is required in IDDM patients undergoing SES implantation.

Randomized Comparison of Sirolimus-Eluting Stent Versus Standard Stent for Percutaneous Coronary Revascularization in Diabetic Patients

Background— Outcomes after percutaneous coronary interventions in diabetic patients are shadowed by the increased rate of recurrence compared with nondiabetic patients.

Methods and Results— We conducted a multicenter, randomized trial to demonstrate the efficacy of sirolimus-eluting stents compared with standard stents to prevent restenosis in diabetic patients with de novo lesions in native coronary arteries. The primary end point of the trial was in-segment late lumen loss as assessed by quantitative coronary angiography at 9-month follow-up. The trial was stratified by diabetes treatment status. One hundred sixty patients were randomized to sirolimus-eluting stents (80 patients; 111 lesions) or standard stent implantation (80 patients; 110 lesions). On average, reference diameter was 2.34±0.6 mm, lesion length was 15.0±8 mm, and 13.1% of lesions were chronic total occlusions. In-segment late lumen loss was reduced from 0.47±0.5 mm for standard stents to 0.06±0.4 mm for sirolimus stents ( P <0.001). Target-lesion revascularization and major adverse cardiac event rates were significantly lower in the sirolimus group (31.3% versus 7.3% and 36.3% versus 11.3%, respectively; both P <0.001). Non–insulin- and insulin-requiring patients demonstrated similar reductions in angiographic and clinical parameters of restenosis after sirolimus-eluting stent implantation. During the 9-month follow-up, stent thrombosis occurred in 2 patients after standard stent implantation. Conversely, this phenomenon was not seen in the sirolimus stent group.

Conclusions— This randomized trial demonstrated that sirolimus stent implantation is safe and efficacious in reducing both angiographic and clinical parameters of restenosis compared with standard stents in diabetic patients with de novo coronary stenoses.

Complete myocardial revascularization: between myth and reality

Myocardial revascularization in patients with multi-vessel coronary artery disease may be accomplished, by percutaneous interventions or surgery, either on all diseased lesions or directed to selectively targeted coronary segments. The extent of planned revascularization is often a major determinant of treatment strategy. Revascularization of all diseased coronary segments-complete myocardial revascularization-has a potential long-term benefit, but is more complex and may increase in-hospital untoward events. Revascularization may otherwise be incomplete, either because of the operator's inability to treat all diseased coronary segments or by choice of deciding to selectively revascularize only large areas of myocardium at risk. Although incomplete revascularization may negatively affect long-term outcomes, it may be, when wisely chosen, the preferred treatment strategy in selected patient categories because of its lower immediate risks. The patient's clinical status, ventricular function, and the presence of co-morbidities may orient clinical decisions in favour of incomplete revascularization.

Diabetes mellitus and unstable coronary artery disease: improved clinical outcome of coronary artery stenting in an era of glycoprotein IIb/IIIa inhibitors and lipid-lowering therapy

OBJECTIVE

The short- and long-term clinical outcomes of coronary artery stenting in diabetic patients with unstable coronary artery disease were assessed and compared with a cohort of non-diabetic patients in the context of platelet glycoprotein IIb/IIIa inhibitors and lipid-lowering therapy.

METHODS

The study population comprised 252 consecutive patients with unstable angina who underwent coronary artery stenting; of these 46 were diabetic and 206 were non-diabetic. In-hospital results and clinical outcome during follow-up (24 +/- 13 months, range 7-56 months) were obtained in all patients without major in-hospital complications. Survival curves and multivariate models for any late clinical event were reported.

RESULTS

A high clinical success rate and no difference in in-hospital complications between the two groups of patients were observed. Complete revascularization rate was similar in diabetic and non-diabetic patients (48% compared with 52%). A greater proportion of diabetic than non-diabetic patients received IIb/IIIa inhibitors during the procedure and lipid-lowering drugs at hospital discharge (87% compared with 46%, P=0.001 and 83% compared with 61%, P=0.006 respectively). At 2-year clinical follow-up, the incidences of death and myocardial infarction were similar in both groups; the need for any revascularization was only slightly higher in diabetic patients (P=NS). Incomplete revascularization and multi-vessel disease were independent predictors of any revascularization.

CONCLUSIONS

Coronary artery stenting combined with glycoprotein IIb/IIIa inhibitor infusion and long-term lipid-lowering therapy is an effective therapeutic strategy in diabetic patients with unstable coronary artery disease and is associated with good short- and long-term results, comparable to those observed in non-diabetic patients.

RAGE axis: Animal models and novel insights into the vascular complications of diabetes

Receptor for AGE (RAGE) is a multi-ligand member of the immunoglobulin superfamily of cell surface molecules. Engagement of RAGE by its signal transduction ligands evokes inflammatory cell infiltration and activation in the vessel wall. In diabetes, when fueled by oxidant stress, hyperglycemia, and superimposed stresses such as hyperlipidemia or acute balloon/endothelial denuding arterial injury, the ligand-RAGE axis amplifies vascular stress and accelerates atherosclerosis and neointimal expansion. In this brief synopsis, we review the use of rodent models to test these concepts. Taken together, our findings support the premise that RAGE is an amplification step in vascular inflammation and acceleration of atherosclerosis. Future studies must rigorously test the potential impact of RAGE blockade in human subjects; such trials are on the horizon.

RAGE and its ligands: a lasting memory in diabetic complications?

The complications of diabetes are myriad and represent a rising cause of morbidity and mortality, particularly in the Western world. The update of the Diabetes Control and Clinical Trials Group/Epidemiology of Diabetes Interventions and Complications Research Group (DCCT/EDIC) suggested that previous strict control of hyperglycaemia was associated with reduced carotid atherosclerosis compared to conventional treatment, even after levels of glycosylated haemoglobin between the two treatment groups became indistinguishable. These intriguing findings prompt the key question, why does the blood vessel 'remember'? This review focuses on the hypothesis that the ligand/RAGE axis contributes importantly to glycaemic 'memory'. Studies in rodent models of diabetes suggest that blockade or genetic modification of RAGE suppress diabetes-associated progression of atherosclerosis, exaggerated neointimal expansion consequent to acute arterial injury, and cardiac dysfunction. We propose that therapeutic RAGE blockade will intercept maladaptive diabetes-associated memory in the vessel wall and provide cardiovascular protection in diabetes.

Glycation, inflammation, and RAGE: a scaffold for the macrovascular complications of diabetes and beyond

The cardiovascular complications of diabetes represent the leading cause of morbidity and mortality in affected subjects. The impact of hyperglycemia may be both direct and indirect: indirect consequences of elevated blood glucose lead to generation of advanced glycation endproducts, the products of nonenzymatic glycation/oxidation of proteins/lipids that accumulate in the vessel wall, and are signal transduction ligands for Receptor for AGE (RAGE). Although enhanced in diabetes, AGE accumulation also occurs in euglycemia and aging, albeit to lower degrees, driven by oxidant stress and inflammation. In hyperglycemia, production of 3-deoxyglucosone, at least in part via the polyol pathway, provides an amplification loop to sustain AGE generation, oxidant stress, and vascular activation. Furthermore, recruitment of inflammatory cells bearing S100/calgranulins, also ligands for RAGE, augments vascular dysfunction. We hypothesize that activation of RAGE is a final common pathway that transduces signals from these diverse biochemical and molecular species, leading to cardiovascular perturbation. Ultimately, these pathways synergize to construct a scaffold on which the complications of diabetes in the vasculature and heart may be built. We propose that antagonism of RAGE will provide a unique means to dismantle this scaffold and, thereby, suppress initiation/progression of vascular disease and cardiac dysfunction that accompany diabetes and aging.

Short- and long-term results after multivessel stenting in diabetic patients

OBJECTIVES

The present study evaluated clinical outcomes in diabetic patients after multivessel stenting.

BACKGROUND

Multivessel angioplasty studies have reported decreased survival in diabetic patients undergoing conventional balloon angioplasty compared with coronary artery bypass graft surgery (CABG). However, several studies have demonstrated excellent procedural success and acceptable clinical outcomes after multivessel stenting.

METHODS

Multivessel stenting was performed in 689 patients with 1,639 native coronary lesions. Patients were classified into three groups according to diabetes mellitus (DM) status: 1) no DM (501 patients/1,200 lesions); 2) DM treated with oral agents (102 patients/235 lesions); and 3) DM treated with insulin (86 patients/204 lesions).

RESULTS

Procedural success was high overall. In-hospital CABG was higher in diabetics treated with insulin compared with the other two groups (3.5% vs. 0.4% vs. 1.0%, p = 0.02). There were no significant differences in the incidence of in-hospital cardiac death and myocardial infarction. Diabetic patients treated with oral agents or insulin had higher one-year target lesion revascularization rates than non-diabetic patients (25% vs. 35% vs. 16%, p < 0.001). Lower one-year survival was observed in diabetic patients treated with either oral agents or insulin, compared with non-diabetic patients (85% vs. 86% vs. 95%, p < 0.001). On multivariable analysis, DM was an independent predictor of one-year mortality, myocardial infarction, and target lesion revascularization after multivessel stenting.

CONCLUSIONS

Despite a high technical success rate of multivessel stenting, diabetic patients, especially those treated with insulin, have higher in-hospital CABG, higher subsequent revascularization rates, and lower one-year survival than non-diabetic patients.

Outcomes in patients with diabetes mellitus undergoing percutaneous coronary intervention in the current era: a report from the Prevention of REStenosis with Tranilast and its Outcomes (PRESTO) trial

BACKGROUND

Diabetes portends an adverse prognosis in patients undergoing percutaneous coronary intervention (PCI). Whether improvements in current clinical practice (stents, IIb/IIIa antagonists) have resulted in substantial improvement of these outcomes remains an issue. The aim of this study was to determine the influence of diabetes on 9-month outcomes of patients undergoing PCI in the current era.

METHODS AND RESULTS

The 11 482 patients enrolled in the Prevention of REStenosis with Tranilast and its Outcomes (PRESTO) Trial were stratified according to the presence (n=2694) or absence (n=8798) of diabetes. Diabetic patients were older; were more likely to be female; had a higher proportion of congestive failure, hypertension, prior CABG, and unstable angina; and had higher body mass index and lower ejection fraction than nondiabetic patients (P<0.01 for all comparisons). The degree of multivessel disease was similar between the two groups. American College of Cardiology/American Heart Association type C lesions were more common in diabetic patients (17% versus 15%, P<0.01). Angiographic and procedural success rates and in-hospital events were similar between the two groups. The primary end point of death, myocardial infarction, or target vessel revascularization (TVR) was analyzed as time-to-first event within 9 months of the index PCI. After adjusting for certain baseline characteristics, diabetes was independently associated with death at 9 months (relative risk [RR], 1.87; 95% CI, 1.31 to 2.68, P<0.01) and with an increased likelihood of TVR (RR, 1.27; 95% CI, 1.14 to 1.42, P<0.01), as well as the composite end point of death/myocardial infarction/TVR (RR, 1.26; 95% CI, 1.13 to 1.40, P<0.01).

CONCLUSIONS

Despite advances in interventional techniques, diabetes remains a significant independent predictor of adverse events in the intermediate term after PCI.

The BBZDR/Wor Rat Model for Investigating the Complications of Type 2 Diabetes Mellitus

Congenic and inbred strains of rats offer researchers invaluable insight into the etiopathogenesis of diabetes and associated complications. The inbred Bio-Breeding Zucker diabetic rat (BBZDR)/Wor rat strain is a relatively new and emerging model of type 2 diabetes. This strain was created by classical breeding methods used to introgress the defective leptin receptor gene (Lepr(fa)) from insulin-resistant Zucker fatty rats into the inbred BBDR/Wor strain background. The diabetic male BBZDR/Wor rat is homozygous for the fatty mutation and shares the genetic background of the original BB strain. Although lean littermates are phenotypically normal, obese juvenile BBZDR/Wor rats are hyperlipidemic and hyperleptinemic, become insulin resistant, and ultimately develop hyperglycemia. Furthermore, the BBZDR/Wor rat is immune competent and does not develop autoimmunity. Similar to patients with clinical diabetes, the BBZDR/Wor rat develops complications associated with hyperglycemia. The BBZDR/Wor rat is a model system that fully encompasses the ability to study the complications that affect human type 2 diabetic patients. In this review, recent work that has evaluated type 2 diabetic complications in BBZDR/Wor rats is discussed, including the authors' preliminary unpublished studies on cardiovascular disease.

Blockade of receptor for advanced glycation endproducts: a new target for therapeutic intervention in diabetic complications and inflammatory disorders

The glycation and oxidation of proteins/lipids leads to the generation of a new class of biologically active moieties, the advanced glycation endproducts (AGEs). Recent studies have elucidated that carboxymethyllysine (CML) adducts of proteins/lipids are a highly prevalent AGE in vivo. CML-modified adducts are signal transduction ligands of the receptor for AGE (RAGE), a member of the immunoglobulin superfamily. Importantly, CML-modified adducts accumulate in diverse settings. In addition to enhanced formation in settings of high glucose, these adducts form in inflammatory milieu. Studies performed both in vitro and in vivo have suggested that the proinflammatory/tissue destructive consequences of RAGE activation in the diabetic/inflamed environment may be markedly attenuated by blockade of the ligand-RAGE axis. Here, we will summarize the known consequences of RAGE activation in the tissues and highlight novel areas for therapeutic intervention in these disease states.

Sex differences in the prognostic importance of diabetes in patients with ischemic heart disease undergoing coronary angiography

OBJECTIVE

Women with ischemic heart disease have poorer outcomes than men and are suggested to have greater risk associated with diabetes. We evaluated the prognosis associated with diabetes, in analyses stratified by sex, to determine whether similar differences are seen in a large unselected cohort of patients.

RESEARCH DESIGN AND METHODS

Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), a clinical data collection and follow-up initiative capturing all patients undergoing cardiac catheterization in Alberta, Canada, the relative significance of diabetes on long-term survival in 13152 men and 4249 women was evaluated in patients presenting with or without myocardial infarction and according to first treatment received.

RESULTS

The 1-year mortality rates were 4.7% and 6.8% in men and women (P < 0.001), 4.1% and 7.4% in nondiabetic and diabetic men (P < 0.001), and 5.8% and 9.6% in nondiabetic and diabetic women, respectively (P < 0.001). The risk-adjusted Cox proportional hazard ratios associated with diabetes in myocardial infarction were 1.03 in men and 1.20 in women. The diabetes hazard ratios for percutaneous coronary intervention were 1.28 in men and 1.40 in women, 1.23 in men and 1.32 in women for bypass surgery, and 1.26 in men and 1.31 in women for medical therapy (P = NS for all diabetes hazard ratio comparisons between men and women).

CONCLUSIONS

Hazard ratios quantifying the adverse prognosis associated with diabetes in patients undergoing angiography are consistently higher among women than men, but the differences across sexes are not statistically significant. These slight sex differences noted in the APPROACH registry are similar to previously reported findings and may be clinically important.