Diabetes

Diabetes and coronary artery disease

  • Diabetes mellitus is the name for a group of disorders characterized by hyperglycemia (fasting blood glucose =126 mg/dL)1
  • The majority of diabetics die of cardiovascular disease2
  • Diabetes is associated with more extensive coronary artery disease and unstable syndromes than non-diabetics3
  • There are 10.3 million diagnosed diabetics in the US and an estimated 5.4 million are undiagnosed. This is expected to double in the next 10 years4

Picture of diabetic vascular pathology and PCI

Patients with diabetes mellitus are at significantly increased risk for cardiovascular complications, and diabetic patients undergoing PCI experience significantly worse outcomes than non-diabetics. Approximately 15% to 25% of patients undergoing PCI are diabetic.6

The impact of diabetes on a person may result in long, diffuse lesions (sometimes calcified), friable vessels, with an increased propensity for thrombosis. Therefore, diabetic patients undergoing PCI present significant challenges to the interventionalist. Many physicians have commented that they find the patient with diabetes more challenging than the patient with acute MI. This is due primarily to the unpredictable reaction of diabetic vessels to the angioplasty procedure. They dissect more frequently due to the calcium and the vessels are generally friable (fragile). In addition, the small size of the diabetic coronary vessels creates additional interventional challenges.

Using ReoPro (abciximab) means treating diabetic patients undergoing PCI with confidence

In the EPISTENT7 trial, ReoPro decreased the primary composite endpoint of death, MI, or, urgent intervention at 30 days (ReoPro + stent 5.3%, placebo + stent 10.8%, P<.001, relative reduction 51%; ReoPro + balloon 6.9%, placebo + stent 10.8%, P=.007, relative reduction 36%).

The event rate of the primary endpoint was evaluated at 30 days and 6 months in diabetic and non-diabetic patients:

Chart showing that the event rate of the primary endpoint was evaluated at 30 days and 6 months in diabetic and non-diabetic patients

Mortality was assessed through 1 year in the entire patient population as well as in the diabetic and non-diabetic patients:

Chart showing improved survival in stent patients

Data from earlier studies with balloon angioplasty were not suggestive of the same mortality benefit.

ACC/AHA guidelines for the management of patients with UA and non-ST-segment elevation MI10

Special groups: Diabetes mellitus

Class IIa

  1. PCI for diabetic patients with one-vessel disease and inducible ischemia (level of evidence: B)
  2. Abiciximab for diabetics treated with coronary stenting (level of evidence: B)

Definitions

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
Evidence B: Data was derived from a limited number of randomized trials that involved small numbers of patients or from careful analyses of nonrandomized studies or observational registries.

For definitions of class and level of evidence, see: http://www.acc.org/qualityandscience/clinical/statements.htm

Page References
  1. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 1997;20:1183-1197.
  2. Carr ME. Diabetes mellitus: A hypercoagulable state. J Diabetes Compl. 2001;15:44-54.
  3. Kip KE, Faxon DP, Detre KM et al. Coronary angioplasty in diabetic patients: the national heart, lung, and blood institute percutaneous transluminary coronary angioplasty registry. Circulation 1996;94:1818-1825.
  4. Amos AF, McCartney DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabet Med 1997;14(suppl):S1-85.
  5. Tschoepe D, Roesen P. Heart disease in diabetes mellitus: A challenge for early diagnosis and intervention. Exp Clin Endocrinol Diabetes 1998;106:16-24.
  6. Braunwald E, et al. J Am Coll Cardiol. 2000;36:970-1062.
  7. Reference for top left graph: The EPISTENT Investigators. Randomised placebo-controlled and balloon angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein IIb/IIIa blockade. Lancet. 1998;352:87-92.
  8. Reference for top right graph: Marso SP, Lincoff AM, Ellis SG, et al., for the EPISTENT Investigators. Optimizing the percutaneous interventional outcomes for patients with diabetes mellitus: results of the EPISTENT (Evaluation of platelet IIb/IIIa inhibitor for stenting trial) diabetic substudy. Circulation. 1999;100:2477-2484.
  9. Topol EJ, Mark DB, Lincoff AM et al. Outcomes at 1 year and economic implications of platelet glycoprotein IIb/IIIa blockade in patients undergoing coronary stenting: results from a multicentre randomised trial. Lancet 1999;354:2019-2024.
  10. Braunwald E, Antman EM, Beasley JW et al. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). 2002. Available at: http://www.acc.org/qualityandscience/clinical/statements.htm

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