Coronary stenting in diabetic patients: Results from the ROSETTA registry

Impact of acute gain on clinical outcomes of patients treated with sirolimus-eluting stent. - A sub-analysis study from the STLLR trial-

BACKGROUND

Geographical miss (GM), representing suboptimal drug-eluting stent deployment, is associated with an increased risk of target lesion revascularization (TLR) and myocardial infarction. The impact of suboptimal stenting techniques on clinical outcomes in diabetics remains unknown.

METHODS AND RESULTS

Stent deployment Techniques on cLinicaL outcomes of patients treated with the cypheR(TM) stent (STLLR) is the first multicenter, large trial to prospectively evaluate outcomes associated with sirolimus-eluting stent (SES) deployment techniques. Axial GM and longitudinal GM (LGM), defined as a balloon injured segment or a diseased segment not covered by a SES, were assessed by an independent core laboratory. One-year outcomes between diabetics and non-diabetics and their relationship with GM were assessed. This substudy included 1,336 patients, 28.8% with diabetes. In non-LGM patients, TLR was similarly low in both diabetics and non-diabetics (2.0% vs. 2.0%, P=NS). However, TLR increased 4.1 times in diabetics (8.0%) and 1.9 times in non-diabetics (3.8%) in the presence of LGM (P=0.03). Axial GM had no impact on outcomes. By univariate analysis, stent length, acute gain, and LGM were the predictors of TLR in the total cohort. However, by multivariate analysis, acute gain was the only predictor of TLR (P=0.03), independently of LGM or diabetes.

CONCLUSIONS

Acute gain is the exclusive predictor of TLR after SES implantation. Particularly in diabetics, the negative impact of LGM on TLR seems to be amplified. Diligent SES deployment for larger acute gain is critical to improve clinical outcomes.

Inhibition of in-stent restenosis by oral copper chelation in porcine coronary arteries

Stress-induced release of IL-1alpha and fibroblast growth factor-1 is dependent on intracellular copper and is a major driver of neointimal hyperplasia. Therefore, we assessed the effect of tetrathiomolybdate (TTM), a clinically proven copper chelator, on in-stent restenosis. Nine pigs were treated with TTM (5 mg/kg po) twice daily for 2 wk before stent implantation and for 4 wk thereafter, and nine pigs served as controls. In-stent restenosis was assessed by quantitative coronary angiography (QCA), intravascular ultrasound (IVUS), and histomorphometry. Serum ceruloplasmin activity was used as a surrogate marker of copper bioavailability. In TTM-treated animals, ceruloplasmin dropped 70 +/- 10% below baseline levels. Baseline characteristics were comparable in TTM-treated and control animals. At 4-wk follow-up, all parameters relevant to in-stent restenosis were significantly reduced in TTM-treated animals: minimal lumen diameter by QCA was 2.03 +/- 0.57 and 1.47 +/- 0.45 mm in TTM-treated and control animals, respectively (P < 0.05), percent stenosis diameter was 39% less in TTM-treated animals (27.1 +/- 16.6% vs. 44.5 +/- 16.1%, P < 0.05), minimal lumen area by IVUS was 60% larger in TTM-treated animals (4.27 +/- 1.56 vs. 2.67 +/- 1.19 mm(2), P < 0.05), and neointimal volume by histomorphometry was 37% less in TTM-treated animals (34.9 +/- 11.5 vs. 55.2 +/- 19.6 mm(3), P < 0.05). We conclude that systemic copper chelation with a clinically approved chelator significantly inhibits in-stent restenosis.

Predictors of long-term outcome following percutaneous coronary intervention in patients with type 2 diabetes mellitus

OBJECTIVES

Diabetes has a major impact on the long-term outcome following percutaneous coronary intervention, being a major risk factor for restenosis. We aimed at assessing the clinical, hemodynamic and angiographic factors that predict outcome in this high-risk group.

METHODS

Diabetic patients who underwent percutaneous coronary intervention during the period 1996-2000 were identified retrospectively, and their medical records, hemodynamic data and angiograms studied at the time of their procedure. Angiographic data were analyzed to determine procedural factors, quantitative angiographic results of their percutaneous coronary intervention and severity and extent scores of coronary artery disease. Clinical follow-up was obtained in 99.7% to a mean time of 782+/-153 days after percutaneous coronary intervention.

RESULTS

A total of 327 consecutive diabetic patients underwent percutaneous coronary intervention on 389 lesions. The overall procedural success rate was 96.2%; however, during follow-up, 40.2% of patients had an adverse cardiac event. The strongest independent predictors of adverse outcome were presence of renal disease, need for medical diabetic treatment, and the extent of coronary artery disease as assessed by the extent score, but not the duration of diabetes or glycemic control. Other factors, which are often predictive of short-term outcome in a general population, such as vessel diameter, lesion length, and severity of coronary artery disease, were not predictive of outcome.

CONCLUSIONS

In patients with type 2 diabetes mellitus, the extent of the coronary arteries involved with atheroma as well as systemic factors such as renal involvement are the best predictors of long-term outcome following percutaneous coronary intervention.

Meta-analysis of the effect of diabetes on restenosis rates among patients receiving coronary angioplasty stenting

OBJECTIVE

Coronary artery disease is a significant source of morbidity and mortality in patients with diabetes. Angioplasty has been associated with higher rates of restenosis in patients with diabetes. Numerous studies have been performed to determine whether coronary artery stenting would be useful in decreasing rates of restenosis of coronary vessels in patients with diabetes. This meta-analysis was conducted to determine the effect of diabetes on angiographic restenosis in patients undergoing coronary stenting.

RESEARCH DESIGN AND METHODS

Six studies were included comprising 6,236 individuals-1,166 with diabetes and 5,070 without. The relationships between restenosis rates and age, the percentage of the study population that was male, and the percentage of the study population receiving insulin therapy were examined.

RESULTS

The average restenosis rates among patients with and without diabetes were 36.7 and 25.9%, respectively. Restenosis rates were higher among older populations and populations in which a greater percentage of patients with diabetes were treated with insulin, but they did not vary according to the percentage of men in the studies. The odds ratio of coronary artery restenosis associated with diabetes was 1.61 (95% CI 1.21-2.14, P = 0.004) in univariate logistic regression models, but decreased to 1.30 (0.99-1.70, P = 0.055) after controlling for age in multivariate models, suggesting that the higher restenosis rates found in patients with diabetes can in good part be explained by the older ages of patients with diabetes in these studies.

CONCLUSIONS

Although diabetes is a risk factor for restenosis after coronary angioplasty stenting, the apparent effect of diabetes on restenosis rates in the published literature is overstated and was reduced in this meta-analysis by approximately half after adjusting for differences in age.

Intracoronary brachytherapy, a promising treatment option for diabetic patients: Results from a European multicenter registry (RENO)

Despite advances in the interventional treatment of coronary disease, diabetics still have double the case fatality rate as nondiabetics. The purpose of this analysis from the Radiation in Europe With Novoste (RENO) registry was to assess the clinical and angiographic 6-month outcome of diabetic patients in comparison to nondiabetic patients after localized beta-radiation. A total of 1,098 patients (83.8% with in-stent restenosis) treated with the Novoste Beta-Cath system in Europe were enrolled in the RENO registry. Diabetes was, irrespective of the type of lesion treated, no significant risk factor for major adverse cardiac events or target vessel revascularization. Individuals with diabetes (n = 256) and without diabetes (n = 833) displayed no significant differences concerning clinical or angiographic endpoints. Vascular brachytherapy appears to be the first technique to even out the increased risk of diabetic patients undergoing percutaneous coronary interventions in the routine clinical setting. Thus, intracoronary brachytherapy represents a promising treatment option for diabetic patients.

Comparison of in-hospital and one-year outcomes in patients with and without diabetes mellitus undergoing percutaneous catheter intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry)

Extrapolation of improvements in percutaneous coronary intervention (PCI) and outcomes to patients with diabetes has not been systematically examined in clinical practice. Two waves of consecutive patients (n = 4,629) who underwent PCI from July 1997 to June 1999 enrolled in the National Heart, Lung, and Blood Institute Dynamic Registry comprise the study population. There were 1,058 patients with treated diabetes and 3,571 patients without clinically evident diabetes. As a group, patients with diabetes tended to have more clinical, angiographic, and procedural risk factors. Although crude in-hospital mortality rates were higher in patients with diabetes (diabetics 2.3%, nondiabetics 1.3%; p = 0.02), the adjusted risk of in-hospital death (odds ratio 1.46, 95% confidence interval [CI] 0.80 to 2.66) was not significantly different. At 1 year, patients with diabetes had a significantly higher adjusted risk of mortality (risk ratio [RR] 1.80, 95% CI 1.35 to 2.41) and need for repeat revascularization (RR 1.40, 95% CI 1.13 to 1.74). There was a significant interaction between stent use and diabetic status with the need for repeat revascularization (adjusted RR in nondiabetics 0.73, 95% CI 0.61 to 0.88; adjusted RR in patients with diabetes 1.20, 95% CI 0.88 to 1.65). Beta blockers at the time of hospital discharge were significantly associated with reduced mortality rates at 1 year in both groups.