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Dai Y, Takagi A, Konishi H, Miyazaki T, Masuda H, Shimada K, Miyauchi K, Daida H. Long-term outcomes of rotational atherectomy in coronary bifurcation lesions. Exp Ther Med 2015; 10:2375-2383. [PMID: 26668644 DOI: 10.3892/etm.2015.2817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 07/23/2015] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to determine the long-term outcomes of bifurcation lesions following a rotational atherectomy (ROTA). In this retrospective study, patients that had undergone a ROTA of the bifurcation coronary lesions in Juntendo University Hospital (Tokyo, Japan) were enrolled between January 2007 and December 2009, and received follow-up for a median duration of 48 months (range, 12-84 months). A total of 337 patients were enrolled. Each patient was treated with an average of 1.2±0.4 ROTA burrs (mean size, 2.9±0.3 mm). Baseline lesion length, reference diameter, minimal lumen diameter (MLD) and percentage of diameter stenosis (%DS) prior to the procedure were comparable between the DM and non-DM patients. Furthermore, MLD, %DS and acute gain following the procedure were similar between the two groups. At follow-up, DM patients exhibited a significantly decreased MLD (1.97±0.92 vs. 2.26±0.73 mm; P=0.0038), increased %DS (27.9±21.3 vs. 20.2±13.3%; P=0.022) and late loss (0.70±0.45 vs. 0.42±0.36 mm; P=0.0047) compared with the non-DM patients. Follow-up examinations (mean duration, 52.2±19.4 months) revealed that the DM patients experienced significantly higher rates of target lesion revascularization (TLR) [28 (15.7%) vs. 8 (5.0%); P=0.0011], target lesion (TL) restenosis [46 (25.8%) vs. 20 (12.6%); P=0.0019] and major adverse cardiac events (MACE) [36 (20.2%) vs. 19 (12.0%), P=0.039] compared with the non-DM patients. Although the usage of ROTA and drug-eluting stent evidently improved long-term outcomes in patients with bifurcation lesions, DM remained an independent risk factor for TLR, TL restenosis and MACE. Therefore, the management of DM in bifurcation lesions treated with ROTA requires increased investigation in future clinical practice.
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Affiliation(s)
- Yuxiang Dai
- Department of Cardiology, Juntendo University Hospital, Tokyo 113-8421, Japan ; Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Atsutoshi Takagi
- Department of Cardiology, Juntendo University Hospital, Tokyo 113-8421, Japan
| | - Hakuoh Konishi
- Department of Cardiology, Juntendo University Hospital, Tokyo 113-8421, Japan
| | - Tetsuro Miyazaki
- Department of Cardiology, Juntendo University Hospital, Tokyo 113-8421, Japan
| | - Hiroshi Masuda
- Department of Cardiology, Juntendo University Hospital, Tokyo 113-8421, Japan
| | - Kazunori Shimada
- Department of Cardiology, Juntendo University Hospital, Tokyo 113-8421, Japan
| | - Katsumi Miyauchi
- Department of Cardiology, Juntendo University Hospital, Tokyo 113-8421, Japan
| | - Hiroyuki Daida
- Department of Cardiology, Juntendo University Hospital, Tokyo 113-8421, Japan
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Bundhun PK, Li N, Chen MH. Adverse cardiovascular outcomes between insulin-treated and non-insulin treated diabetic patients after percutaneous coronary intervention: a systematic review and meta-analysis. Cardiovasc Diabetol 2015; 14:135. [PMID: 26446829 PMCID: PMC4597459 DOI: 10.1186/s12933-015-0300-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (DM) patients have worse adverse cardiovascular outcomes after Percutaneous Coronary Intervention (PCI). However, the adverse cardiovascular outcomes between insulin-treated and non-insulin treated DM patients have been a subject of debate. We sought to compare the short-term (<1 year) and long-term (≥1 year) cardiovascular outcomes between insulin-treated and non-insulin treated DM patients after PCI. METHODS Medline and Embase databases were searched for studies by typing 'diabetes and percutaneous coronary intervention/PCI' or 'insulin-treated and non-insulin treated diabetes mellitus and PCI'. Endpoints included adverse cardiovascular outcomes reported in these DM patients during the corresponding follow-up periods. Odd Ratio (OR) with 95% confidence interval (CI) was used to express the pooled effect on discontinuous variables and the pooled analyses were performed with RevMan 5.3. RESULTS 21 studies have been included in this meta-analysis consisting of a total of 21,759 diabetic patients (6250 insulin-treated and 15,509 non-insulin treated DM patients). Short term mortality, myocardial infarction, target lesion revascularization, major adverse cardiac effects and, stent thrombosis were significantly higher in insulin-treated diabetic patients (OR 1.69, 95% CI 1.40-2.04, p < 0.00001), (OR 1.40, 95% CI 1.16-1.70, p = 0.0005), (OR 1.37, 95% CI 1.06-1.76, p = 0.02), (OR 1.46, 95% CI 1.22-1.76, p < 0.0001) and (OR 1.66, 95% CI 1.16-2.38, p = 0.005) respectively. Long-term cardiovascular outcomes were also significantly higher in insulin-treated DM patients. CONCLUSION Insulin treatment in these DM patients was associated with a significantly higher short and long-term adverse cardiovascular outcomes after PCI compared to those DM patients not treated by insulin therapy.
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Affiliation(s)
- Pravesh Kumar Bundhun
- Institute of Cardiovascular Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China.
| | - Nuo Li
- Institute of Cardiovascular Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China.
| | - Meng-Hua Chen
- Institute of Cardiovascular Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China.
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Sarma R, Prajapati J, Raheem A, Thakkar K, Kothari S, Thakkar A. Nine-Months Clinical Outcome of Biodegradable Polymer Coated Sirolimus-eluting Stent System: A Multi-Centre "Real-World" Experience. J Clin Diagn Res 2015; 9:OC23-6. [PMID: 26435986 DOI: 10.7860/jcdr/2015/14060.6403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 07/19/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND The main culprit in first-generation drug eluting stents is 'durable' polymer, whose continuous presence may impair arterial healing and ultimately have a negative impact on late outcomes. The main enigma behind the biodegradable polymer usage is its degradation after elution of drug. This reduces adverse events in unselected patients with complex coronary artery lesions treated with biodegradable polymer coated sirolimus-eluting stents. AIM The aim of the INDOLIMUS-G Registry was to evaluate safety and efficacy of the Indolimus (Sahajanand Medical Technologies Pvt. Ltd., Surat, India) sirolimus-eluting stents in large cohorts of unselected patients with complex coronary artery lesions. MATERIALS AND METHODS It is a multi-centre, non-randomized retrospective registry with a clear aim of evaluating safety and efficacy of the Indolimus sirolimus-eluting stents in consecutive patients enrolled between April 2012 and May 2014. The primary end-point of the study was major adverse cardiac events (MACE), which is a composite of cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR) and stent thrombosis (ST) at the end of follow-up. Clinical follow-up were scheduled at the end of 30-days, 6-months, and 9-months period. RESULTS The mean age of enrolled patients was 52.6 ± 11.0 years. A total of 1137 lesions were intervened successfully with 1242 stents (1.09 ± 0.30 stent per lesion). The average stent length and diameter was 27.42 ± 9.01 mm and 3.12 ± 0.36 mm respectively. There were 740 (73.40%) male patients, indicating their high prevalence. Diabetes, hypertension and totally occluded lesions were found in 372 (36.90%), 408 (40.47%) and 170 (16.86%) patients, respectively. This showed that study also included high risk complex lesions and not ideal recruited lesions. The incidence of MACE at 30-days, 6-months and 9-months were 3 (0.30%), 18 (1.80%) and 22 (2.20%) respectively. At 9-months, TLR was found in 6 (0.50%) patients. There were 2 (0.20%) cases of ST, 10 (1.0%) cases of MI and 4 (0.40%) cases of cardiac death at 9-month follow-up. CONCLUSION The lower incidence of MACE, TLR and ST at 9-month follow-up clearly delineates safety and efficacy of Indolimus SES in large cohorts of unselected patients with complex coronary lesions.
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Affiliation(s)
- Raghava Sarma
- Interventional Cardiologist, Lalitha Super Specialties Hospital (P) Ltd., Heart and Brain Centre , Kothapet, Guntur, Andhra Pradesh, India
| | - Jayesh Prajapati
- Interventional Cardiologist, Apollo Hospitals , Plot No.1 A, Bhat GIDC Estate, Gandhinagar, Gujarat, India
| | - Asif Raheem
- Interventional Cardiologist, Yashfeen Cardiac Hospital , Navsari, Gujarat, India
| | - Kamlesh Thakkar
- Interventional Cardiologist, Lions Sterling Super Specialty Hospital , Mehsana, Gujarat, India
| | - Shivani Kothari
- Medical Writer, Department of Clinical Trials, Sahajanand Medical Technologies Pvt. Ltd. , Surat, Gujarat, India
| | - Ashok Thakkar
- Senior Manager, Clinical Research and Medical Writing, Department of Clinical Trials, Sahajanand Medical Technologies Pvt. Ltd. , Surat, Gujarat, India
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Favorable Outcomes after Implantation of Biodegradable Polymer Coated Sirolimus-Eluting Stents in Diabetic Population: Results from INDOLIMUS-G Diabetic Registry. Int J Vasc Med 2015; 2015:265670. [PMID: 26421189 PMCID: PMC4572437 DOI: 10.1155/2015/265670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 08/20/2015] [Accepted: 08/20/2015] [Indexed: 11/18/2022] Open
Abstract
Objective. The main aim is to evaluate safety, efficacy, and clinical performance of the Indolimus (Sahajanand Medical Technologies Pvt. Ltd., Surat, India) sirolimus-eluting stent in high-risk diabetic population with complex lesions. Methods. It was a multicentre, retrospective, non-randomized, single-arm study, which enrolled 372 diabetic patients treated with Indolimus. The primary endpoint of the study was major adverse cardiac events (MACE), which is a composite of cardiac death, target lesion revascularization (TLR), target vessel revascularization (TVR), myocardial infarction (MI), and stent thrombosis (ST). The clinical follow-ups were scheduled at 30 days, 6 months, and 9 months. Results. The mean age of the enrolled patients was 53.4 ± 10.2 years. A total of 437 lesions were intervened successfully with 483 stents (1.1 ± 0.3 per lesion). There were 256 (68.8%) male patients. Hypertension and totally occluded lesions were found in 202 (54.3%) and 45 (10.3%) patients, respectively. The incidence of MACE at 30 days, 6 months and 9 months was 0 (0%), 6 (1.6%), and 8 (2.2%), respectively. The event-free survival at 9-month follow-up by Kaplan Meier method was found to be 97.8%. Conclusion. The use of biodegradable polymer coated sirolimus-eluting stent is associated with favorable outcomes. The results demonstrated in our study depict its safety and efficacy in diabetic population.
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Park CS, Chung WB, Choi YS, Kim PJ, Lee JM, Baek KH, Kim HY, Yoo KD, Song KH, Chung WS, Seung KB, Lee MY, Kwon HS. Acute Myocardial Infarction Is a Risk Factor for New Onset Diabetes in Patients with Coronary Artery Disease. PLoS One 2015; 10:e0136354. [PMID: 26295946 PMCID: PMC4546589 DOI: 10.1371/journal.pone.0136354] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/01/2015] [Indexed: 01/04/2023] Open
Abstract
Objective To test the hypothesis that acute myocardial infarction (AMI) might accelerate development of new onset diabetes in patients with coronary artery disease independent of known risk factors. Methods We conducted a retrospective cohort study within COACT (CathOlic medical center percutAneous Coronary inTervention) registry. From a total of 9,127 subjects, 2,036 subjects were diabetes naïve and followed up for at least one year with both index and follow-up laboratory data about diabetes. Cox proportional hazard model was used to derive hazard ratios (HRs) and 95% confidence interval (CI) for new onset diabetes associated with AMI in univariate and multivariate analysis after adjusting several covariates. Results The overall hazard for diabetes was higher in AMI compared to non-AMI patients (p by log rank <0.01) with HR of 1.78 and 95% CI of 1.37–2.32 in univariate analysis. This association remained significant after adjusting covariates (HR, 1.54; 95% CI, 1.14–2.07; p<0.01). AMI was an independent predictor for higher quartile of WBC count in multivariate ordinal logistic regression analysis (OR, 6.75; 95% CI, 5.53–8.22, p<0.01). In subgroup analysis, the diabetogenic effect of AMI was more prominent in the subgroup without MetS compared to MetS patients (p for interaction<0.05). Compared to the reference group of non-AMI+nonMetS, the group of AMI+non-MetS (HR, 2.44; 95% CI, 1.58–3.76), non-AMI+MetS (HR, 3.42; 95% CI, 2.34–4.98) and AMI+MetS (HR, 4.12; 95% CI, 2.67–6.36) showed higher HR after adjusting covariates. However, the hazard was not different between the non-AMI+MetS and AMI+non-MetS groups. Conclusions AMI patients have a greater risk of new-onset diabetes when compared to non AMI patients, especially those with mild metabolic abnormalities.
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Affiliation(s)
- Chul Soo Park
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Center and Cardiology Division, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woo Baek Chung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Center and Cardiology Division, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yun Seok Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Center and Cardiology Division, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Pum Joon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Min Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Center and Cardiology Division, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Ki-Hyun Baek
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee Yeol Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Center and Cardiology Division, Bucheon St. Mary’s Hospital, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Ki Dong Yoo
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Center and Cardiology Division, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Ki-Ho Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Wook Sung Chung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Bae Seung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Man Young Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Center and Cardiology Division, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyuk-Sang Kwon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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Kotani K, Tashiro J, Yamazaki K, Nakamura Y, Miyazaki A, Bujo H, Saito Y, Kanno T, Maekawa M. Investigation of MDA-LDL (malondialdehyde-modified low-density lipoprotein) as a prognostic marker for coronary artery disease in patients with type 2 diabetes mellitus. Clin Chim Acta 2015; 450:145-50. [PMID: 26265234 DOI: 10.1016/j.cca.2015.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 08/01/2015] [Accepted: 08/06/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although increased circulating levels of malondialdehyde-modified low-density lipoprotein (MDA-LDL) are associated with coronary artery disease (CAD), there is no direct evidence that increased MDA-LDL is a prognostic factor for CAD. METHODS Forty-two patients (20 diabetic and 22 non-diabetic patients) who underwent percutaneous coronary intervention (PCI) were enrolled, and their baseline MDA-LDL levels were determined by immunoassay. Follow-up coronary angiography was performed at 2 to 7 months post-PCI. The patients were then divided into 2 groups, with in-stent restenosis (ISR) (n=13) and without ISR (n=29), and the baseline MDA-LDL levels were compared. We also studied 34 diabetics with CAD for up to 57 months until the onset of the next coronary event. RESULTS In the diabetic patients, the mean MDA-LDL level was significantly higher in those with ISR than in those without ISR (151+/-61 vs. 90+/-26 U/l, p=0.010). A baseline MDA-LDL value of 110 U/l for differentiating between diabetics with and without ISR was defined as the cut-off value. Kaplan-Meier analysis demonstrated that a circulating MDA-LDL of ≥ 110 U/l correlated significantly with a higher prevalence of cardiac events than MDA-LDL <110 U/l (p=0.032). CONCLUSIONS Circulating MDA-LDL is a useful prognostic marker for future cardiac event in diabetic patients with CAD.
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Affiliation(s)
- Kazuo Kotani
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan.
| | - Jun Tashiro
- Department of Internal Medicine, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba 290-0512, Japan; Department of Internal Medicine, Matsudo Municipal Hospital, 4005 Kamihongo, Matsudo, Chiba 271-8511, Japan
| | - Kenya Yamazaki
- Department of Internal Medicine, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba 290-0512, Japan; Department of Internal Medicine, Matsudo Municipal Hospital, 4005 Kamihongo, Matsudo, Chiba 271-8511, Japan
| | - Yoshitake Nakamura
- Department of Internal Medicine, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba 290-0512, Japan
| | - Akira Miyazaki
- Department of Internal Medicine, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba 290-0512, Japan
| | - Hideaki Bujo
- Department of Clinical-Laboratory and Experimental-Research Medicine, Toho University Sakura Medical Center, 564-1, Shimoshizu Sakura, Chiba 285-8741, Japan
| | - Yasushi Saito
- Department of Clinical Cell Biology, Chiba University Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Takashi Kanno
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Masato Maekawa
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
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Wiemer M, Danzi GB, West N, Voudris V, Koning R, Hoffmann S, Lombardi M, Mauri J, Babic R, Witherow F. Drug-eluting stents with biodegradable polymer for the treatment of patients with diabetes mellitus: clinical outcome at 2 years in a large population of patients. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2015; 8:153-60. [PMID: 25737640 PMCID: PMC4342370 DOI: 10.2147/mder.s67399] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective This study investigates the safety and efficacy of a third-generation drug-eluting stent (DES) with biodegradable polymer in the complex patient population of diabetes mellitus (DM). Clinical trial registration ISRCTN81649913. Background Percutaneous coronary interventions in patients with DM are associated with a higher incidence of death, restenosis, and stent thrombosis as compared to non-diabetic patients. The use of a DES has been shown to improve outcomes in diabetic patients. Methods Out of 3,067 patients, enrolled in 126 centers worldwide in the NOBORI 2 registry, 888 patients suffered from DM, 213 of them (14%) being insulin-dependent DM (IDDM). Two years’ follow-up has been completed in this study. Results At 1- and 2-year follow-up, 97% and 95% of the patients, respectively, were available. The reported target lesion failure (TLF) rates at 1- and 2-year follow-up were 6.0% and 7.2% in the DM group, respectively, and 3.0% and 4.2% in the non-DM group, respectively (P<0.001 for both years). Inside the DM group, the TLF rates of 9.9% and 11.7% at the 1- and 2-year follow-ups, respectively, in patients with IDDM were significantly higher than the TLF rates of 4.7% and 5.8%, respectively, in the non-IDDM subgroup (P<0.01 for both years). The rate of stent thrombosis at the 2-year follow-up was 1.0% in the DM group and 0.7% in non-DM patients. There were no cases of late, or very late stent thrombosis in IDDM patients. Conclusion The Nobori DES performed well in patients with DM. As expected, patients with DM, particularly those with IDDM, had worse outcomes. However, the absence of late, and very late stent thrombosis in IDDM patients merits further investigation, as this finding might have significant clinical value.
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Affiliation(s)
- Marcus Wiemer
- Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | | | | | | | | | | | | | - Josepa Mauri
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Rade Babic
- Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
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Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Sastry BKS, Kumar N, Menon R, Kapadia A, Sridevi C, Surya Prakash G, Krishna Reddy N, Srinivasa Rao M. Real world experience with an indigenously manufactured stent Cobal C--a retrospective study. Indian Heart J 2014; 66:525-9. [PMID: 25443606 DOI: 10.1016/j.ihj.2014.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Second generation bare metal stents made of cobalt chromium alloy are superior to first generation stain less steel stents. The thin struts are shown to reduce clinical and angiographic adverse outcomes. OBJECTIVE To study the long term clinical and angiographic outcomes in patients who underwent coronary angioplasty with an indigenously made cobalt chromium bare metal stents with thin strut Cobal+C™ (Relisys). METHODS A total of 268 consecutive patients who underwent coronary angioplasty with Cobal+C stents were studied retrospectively. Clinical follow up was done after a minimum period of nine months through telephonic interview and angiographic follow up was done in 80 patients chosen randomly. The end points analyzed included major adverse cardiac events (MACE) at nine months and the rate of binary restenosis at follow up angiogram done between 9 and 15 months post angioplasty. RESULTS Thirty four percent were diabetic and 33% had acute myocardial infarction. Females constituted 17%. Mean stent diameter was 2.88 ± 0.28 and mean stent length 18.8 ± 4.2. MACE at nine months was 4.5% with TLR 0.3%. The rate of binary restenosis was 21%. Patients with longer stent lengths and non-compliance with medications had significantly higher rates of binary restenosis. CONCLUSIONS The use of Relisys Cobal+C stents was associated with good long term clinical and angiographic outcomes as evidenced by low incidence of MACE and binary restenosis rates for a bare metal stent.
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Affiliation(s)
- B K S Sastry
- Consultant Cardiologist, CARE Hospitals, Hyderabad, Telangana, India.
| | | | | | | | - C Sridevi
- CARE Hospitals, Hyderabad, Telangana, India
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WITHDRAWN: A two year analysis of Diabetic subset ‘e-BioMatrix’ prospective, multicentric, all comers registry in India. Indian Heart J 2014. [DOI: 10.1016/j.ihj.2014.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Outcomes of the largest multi-center trial stratified by the presence of diabetes mellitus comparing sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) in patients with coronary artery disease. The Japan drug-eluting stents evaluation: a randomized trial (J-DESsERT). Cardiovasc Interv Ther 2014; 30:103-14. [DOI: 10.1007/s12928-014-0279-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 06/02/2014] [Indexed: 11/26/2022]
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Head-to-head comparison of sirolimus-eluting stents versus paclitaxel-eluting stents in patients undergoing percutaneous coronary intervention: a meta-analysis of 76 studies. PLoS One 2014; 9:e97934. [PMID: 24844284 PMCID: PMC4028235 DOI: 10.1371/journal.pone.0097934] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 04/26/2014] [Indexed: 11/19/2022] Open
Abstract
Background The relative short-, long- and overall-term efficacy and safety of sirolimus-eluting stents (SES, Cypher) compared with paclitaxel-eluting stents (PES, Taxus) in large head-to-head comparisons still remain to be defined. Methods We searched Pubmed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) for articles comparing outcomes of interest between SES and PES without language restriction. Short- (≤1 year), long- (>1 year), and overall-term (the longest follow-up of each study) outcomes were evaluated. The primary endpoint was target lesion revascularization (TLR). Other outcomes of interest were target vessel revascularization (TVR), myocardial infarction, all-cause death, cardiac death, stent thrombosis, major adverse cardiac events (MACEs), restenosis and late lumen loss. Results Seventy-six studies including more than 15000 patients in randomized controlled trials and over 70000 patients in adjusted observational studies were included. At overall-term follow-up, SES significantly reduced TLR (relative risk [RR]: 0.61; 95% confidence interval [CI]: 0.49–0.76), TVR (RR: 0.67; 95% CI: 0.54–0.83), MACE (RR: 0.79; 95% CI: 0.72–0.87), myocardial infarction (RR: 0.85; 95% CI: 0.73–0.99), in-segment restenosis (RR: 0.50; 95% CI: 0.38–0.65), and in-segment late lumen loss (weighted mean difference [WMD]: −0.19; 95% CI: −0.24–−0.14) in randomized controlled trials compared with PES. In addition, lower rates of death (RR: 0.91; 95% CI: 0.83–1.00), any stent thrombosis (RR: 0.62; 95% CI: 0.45–0.86), definite stent thrombosis (RR: 0.59; 95% CI: 0.45–0.77) were found in patients receiving SES in adjusted observational studies. Largely similar results were found at short- and long-term follow-up, and in patients with diabetes, acute myocardial infarction or long lesions. Conclusions SES significantly reduced the short-, long- and overall-term risk of TLR/TVR, MACE, and restenosis, and overall-term risk of myocardial infarction in randomized controlled trials, as compared with PES. Lower rates of death and stent thrombosis were also observed in observational studies in SES-treated patients.
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Kang SH, Park KH, Ahn HS, Park KW, Hong YJ, Koo BK, Jeong MH, Kim HS. Everolimus-eluting versus sirolimus-eluting coronary stents in patients with and without diabetes mellitus. EUROINTERVENTION 2014; 10:74-82. [DOI: 10.4244/eijv10i1a13] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Mizobe M, Hokimoto S, Akasaka T, Arima Y, Kaikita K, Morita K, Miyazaki H, Oniki K, Nakagawa K, Ogawa H. Impact of CYP2C19 polymorphism on clinical outcome following coronary stenting is more important in non-diabetic than diabetic patients. Thromb Res 2014; 134:72-7. [PMID: 24821368 DOI: 10.1016/j.thromres.2014.04.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 04/13/2014] [Accepted: 04/18/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to examine the impact of CYP2C19 genotype on clinical outcome in coronary artery disease (CAD) patients with or without diabetes mellitus (DM). METHODS CYP2C19 polymorphism and DM are associated with increased risk of cardiovascular events during antiplatelet therapy following stent implantation. Platelet reactivity during clopidogrel therapy and CYP2C19 polymorphism were measured in 519 CAD patients (males 70%, age 69 years) treated with stent placement. Patients were divided into two groups; DM (n=249), and non-DM (n=270), and clinical events were evaluated according to the carrier state, which included at least one CYP2C19 loss-of-function allele. RESULTS The level of platelet reactivity and incidence of cardiovascular events were significantly different between Carriers and non-Carriers of the non-DM (platelet reactivity: 4501+/-1668 versus 3691+/-1714AU min, P<0.01; events, 32/178 versus 2/92, P<0.01, respectively), however, there was no difference in clinical outcome in the DM group (events, 34/168 versus 14/81, respectively, P=0.57). Multivariate analysis identified CYP2C19 loss-of-function allele carriage as an independent predictor of cardiovascular events in non-DM, but not in DM (non-DM, HR 7.180, 95% CI, 1.701 to 30.298, P=0.007; DM, HR 1.374, 95% CI, 0.394 to 4.792, P=0.618). CONCLUSION The impact of CYP2C19 polymorphism on clinical outcome seems to be more significant in non-DM compared with DM in patients with coronary stents.
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Affiliation(s)
- Michio Mizobe
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Tomonori Akasaka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuichiro Arima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazunori Morita
- Division of Pharmacology and Therapeutics, Graduate School of Medical and Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroko Miyazaki
- Division of Pharmacology and Therapeutics, Graduate School of Medical and Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kentaro Oniki
- Division of Pharmacology and Therapeutics, Graduate School of Medical and Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazuko Nakagawa
- Division of Pharmacology and Therapeutics, Graduate School of Medical and Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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De Luca G, Schaffer A, Verdoia M, Suryapranata H. Meta-analysis of 14 trials comparing bypass grafting vs drug-eluting stents in diabetic patients with multivessel coronary artery disease. Nutr Metab Cardiovasc Dis 2014; 24:344-354. [PMID: 24373711 DOI: 10.1016/j.numecd.2013.11.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 11/19/2013] [Accepted: 11/23/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM Clinical trials have reported lower mortality and repeated revascularization rate in diabetic patients treated with coronary artery bypass grafting (CABG) as compared to percutaneous revascularization. However, these studies were conducted in the era of bare-metal stents. Therefore, we performed a meta-analysis to compare CABG to PCI with drug-eluting stents (DES) in diabetic patients with multivessel and/or left main disease. METHODS AND RESULTS The literature was scanned by formal search of electronic databases (Medline, EMBASE, and Cochrane databases), and major international scientific session abstracts from 2000 to 2013. Primary endpoint was mortality. A total of 14 (4 randomized and 10 non-randomized) trials were finally included, with a total of 7072 patients. Up to 5 years follow-up, CABG was associated with a reduction in mortality (7.3% vs 10.4%, OR[95%CI] = 0.65[0.55-0.77], p < 0.0001; phet = 0.00001), with similar results in both RCTs (OR[95%CI] = 0.64[0.50-0.82], p = 0.0005) and NRCTs (OR[95%CI] = 0.75[0.6-0.94)], p = 0.01) (p int = 0.93). A significant relationship was observed between risk profile and benefits in mortality with CABG (p < 0.001). CABG reduced target vessel revascularization (TVR; 5.2% vs 15.7%, OR[95%CI] = 0.30[0.25-0.36], p < 0.00001, p het = 0.02), with a relationship between risk profile and the benefits from CABG as compared to DES (p < 0.0001). CABG was associated with a lower rate of MACCE (14.9% vs 22.9%, OR[95%CI] = 0.59[0.51-0.67], p < 0.00001, p het<0.00001) but higher risk of CVA (3.6% vs 1.4%, OR[95%CI] = 2.34[1.63-3.35], p < 0.00001, p het = 0.71). CONCLUSIONS The present meta-analysis demonstrates that among diabetic patients with multivessel disease and/or left main disease, CABG provides benefits in mortality and TVR, especially in high-risk patients but it is counterbalanced by a higher risk of stroke. Future trials are certainly needed in the era of new DES and improved antiplatelet therapies.
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Affiliation(s)
- G De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
| | - A Schaffer
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - M Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - H Suryapranata
- Department of Cardiology, UMC St Radboud, Nijmegen, The Netherlands
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Kedhi E, Généreux P, Palmerini T, McAndrew TC, Parise H, Mehran R, Dangas GD, Stone GW. Impact of coronary lesion complexity on drug-eluting stent outcomes in patients with and without diabetes mellitus: analysis from 18 pooled randomized trials. J Am Coll Cardiol 2014; 63:2111-2118. [PMID: 24632279 DOI: 10.1016/j.jacc.2014.01.064] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 01/04/2014] [Accepted: 01/21/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to investigate whether baseline lesion complexity affects drug-eluting stent (DES) outcomes according to diabetic status. BACKGROUND Previous studies have reported conflicting results regarding DES safety and efficacy in patients with and without diabetes mellitus (DM). METHODS Patient-level data from 18 prospective randomized trials were pooled. DES treatment outcomes in patients with versus without DM were analyzed in 2 propensity score-matched groups further stratified according to lesion complexity (American College of Cardiology and American Heart Association class A/B1 vs. B2/C). Remaining baseline differences were adjusted for by multivariate analysis. RESULTS DM was present in 3,467 of 18,441 patients (18.8%). DM was a predictor of 1-year repeat revascularization (target lesion revascularization: hazard ratio: 1.34; 95% confidence interval: 1.05 to 1.70; target vessel revascularization: hazard ratio: 1.40; 95% confidence interval: 1.15 to 1.72) and cardiac death or myocardial infarction (hazard ratio: 1.40; 95% confidence interval: 1.09 to 1.81). Rates of target lesion and target vessel revascularization were significantly higher in patients with versus those without DM with type B2/C lesions (8.0% vs. 4.5% and 10.6% vs. 5.9%, respectively, p < 0.0001 for both), but not in patients with only type A/B1 lesions (4.6% vs. 4.8%, p = 0.87, and 7.4% vs. 6.8%, p = 0.47, respectively), with a significant interaction between DM and lesion type observed for both endpoints (p = 0.01 and p = 0.02, respectively). No interaction was observed for death or myocardial infarction (p = 0.28). CONCLUSIONS In the DES era, patients with DM remain at increased risk for cardiac death or myocardial infarction. However, DM is a risk factor for repeat revascularization only in those patients with complex lesions; patients with DM and noncomplex lesions have similar rates of 1-year freedom from repeat revascularization as do patients without DM.
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Affiliation(s)
| | - Philippe Généreux
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York; Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | - Tullio Palmerini
- Dipartimento Cardiovascolare, Policlinico Sant' Orsola, Bologna, Italy
| | | | - Helen Parise
- Cardiovascular Research Foundation, New York, New York
| | - Roxana Mehran
- Cardiovascular Research Foundation, New York, New York; Icahn School of Medicine at Mount Sinai, New York, New York
| | - George D Dangas
- Cardiovascular Research Foundation, New York, New York; Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregg W Stone
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York.
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Sirolimus-eluting versus paclitaxel-eluting stents in diabetic and non-diabetic patients within sirolimus-eluting stent restenosis: Results from the ISAR-DESIRE 2 trial. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:69-75. [DOI: 10.1016/j.carrev.2014.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/09/2014] [Accepted: 02/10/2014] [Indexed: 01/22/2023]
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Harskamp RE, Park DW. Percutaneous coronary intervention in diabetic patients: should choice of stents be influenced? Expert Rev Cardiovasc Ther 2014; 11:541-53. [DOI: 10.1586/erc.13.38] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Meliga E, De Benedictis M, Chieffo A, Latib A, Park SJ, Kim YH, Onuma Y, Capranzano P, Jegere S, Makkar R, Palacios I, Buszman P, Bande M, Chakravarty T, Mehran R, Naber C, Scrocca I, Margey R, Leon M, Moses J, Fajadet J, Lefèvre T, Morice MC, Erglis A, Tamburino C, Alfieri O, Conte MR, Serruys PW, Colombo A. Coronary artery bypass graft versus percutaneous coronary intervention with drug-eluting stent implantation for diabetic patients with unprotected left main coronary artery disease: the D-DELTA registry. EUROINTERVENTION 2013; 9:803-8. [PMID: 24280156 DOI: 10.4244/eijv9i7a133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Data regarding the impact on clinical outcomes of PCI with DES implantation vs. CABG to treat unprotected left main coronary artery (ULMCA) disease in diabetic patients are still insufficient. The present study evaluated the short-term and long-term results of percutaneous and surgical revascularisation in diabetic patients with ULMCA disease in a large population. METHODS AND RESULTS A total of 826 diabetic patients with ULMCA stenosis who received DES (n=520) or underwent CABG (n=306) were selected and analysed from the DELTA registry. In-hospital MACCE was significantly higher in the CABG group, mainly driven by a higher incidence of MI. At four-year follow-up, freedom from death and the composite endpoint of death, MI and cerebrovascular accident (CVA) was similar in the two treatment groups (CABG 87.4%, PCI 82.5%, p=0.124, and CABG 85.4%, PCI 78.9%, p=0.11, respectively). Conversely, freedom from TVR and MACCE was significantly higher in the CABG compared to the PCI group (CABG 95.4%, PCI 79.4%, p<0.001, and CABG 81.9%, PCI 64.7%, p<0.001). CONCLUSIONS In diabetic patients with ULMCA disease with/without concomitant multivessel disease, PCI and CABG led to similar results in terms of death, MI and CVA. However, CABG was associated with less MACCE at long-term follow-up, primarily due to the higher repeat revascularisation rate with DES.
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Affiliation(s)
- Emanuele Meliga
- Interventional Cardiology Unit, A.O. Ordine Mauriziano Umberto I, Turin, Italy
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Overgaard CB, Džavík V, Buller CE, Liu L, Banasiak W, Devlin G, Maggioni AP, Leor J, Burton JR, Reis G, Ruzyllo W, Forman SA, Lamas GA, Hochman JS. Percutaneous revascularization and long term clinical outcomes of diabetic patients randomized in the Occluded Artery Trial (OAT). Int J Cardiol 2013; 168:2416-22. [PMID: 23582414 PMCID: PMC10515322 DOI: 10.1016/j.ijcard.2013.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 01/24/2013] [Accepted: 02/11/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) of a persistently totally occluded infarct-related artery (IRA) in stable high-risk patients >24h after myocardial infarction (MI) does not reduce the occurrence of death, re-infarction, or heart failure. Diabetic patients are at higher risk for cardiovascular events; we examined their outcomes overall with PCI and optimal medical therapy alone (MED). METHODS The long-term (7-year) outcomes of 454 diabetic patients (20.6%) randomized to PCI or MED in the Occluded Artery Trial (OAT) were assessed for the composite primary endpoint of death, re-MI, or New York Heart Association class IV heart failure. Diabetics and non-diabetics were compared and outcomes assessed by treatment strategy. RESULTS The 7-year cumulative primary event rate for diabetic patients was 35.0% vs. 19.4% in the non-diabetic cohort (p<0.001). Multivariable analyses revealed diabetes to be an independent predictor (p<0.01) for the primary outcome, fatal or nonfatal recurrent MI, Class IV Heart Failure (HF), and death. The 7-year cumulative primary event rates were 35.3% in the PCI group vs. 34.5% in the medical therapy group in diabetic patients (p=0.19) and 19.3% in the PCI group vs. 19.5% in the medical therapy group in patients without diabetes (p=0.60). CONCLUSIONS Despite the higher overall risk conferred by the presence of diabetes, PCI did not improve clinical outcomes in this subpopulation, and is not indicated in otherwise stable patients with a totally occluded infarct-related artery in the sub-acute phase after MI.
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Affiliation(s)
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Heath Network, Toronto, Ontario, Canada
| | | | - Li Liu
- Clinical Trials and Surveys Corporation, Baltimore, MD, USA
| | | | | | - Aldo P. Maggioni
- Italian Association of Hospital Cardiologist (ANMCO) Research Center, Florence, Italy
| | - Jonathan Leor
- Neufeld Cardiac Research Institute, Tel Hashomer, Israel
| | | | - Gilmar Reis
- Santa Casa de Belo Horizonte, Belo Horizonte, Brazil
| | | | | | - Gervasio A. Lamas
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL, USA
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Secretoneurin gene therapy improves blood flow in an ischemia model in type 1 diabetic mice by enhancing therapeutic neovascularization. PLoS One 2013; 8:e74029. [PMID: 24086307 PMCID: PMC3781158 DOI: 10.1371/journal.pone.0074029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 07/26/2013] [Indexed: 12/21/2022] Open
Abstract
Deficient angiogenesis after ischemia may contribute to worse outcome of peripheral arterial disease in patients with diabetes mellitus. Based on our previous work where we demonstrated that Secretoneurin (SN) is up-regulated under hypoxic conditions and enhances angiogenesis, we analyzed the therapeutic potential of SN gene therapy using a model of severe hind limb ischemia in streptozotocin-induced diabetic mice (STZ-DM). After induction of hind limb ischemia, blood flow was assessed by means of laser Doppler perfusion imaging (LDPI) and increased blood perfusion in the SN-treated animal group was observed. These results were complemented by the clinical observation of reduced necrosis and by an increased number of capillaries and arterioles in the SN-treated animal group. In vitro, we found that SN is capable of promoting proliferation and chemotaxis and reduces apoptosis in HUVECs cultured under hyperglycemic conditions. Additionally, SN activated ERK, eNOS and especially AKT as well as EGF-receptor in hyperglycemic HUVECs. In conclusion, we show that SN gene therapy improves post-ischemic neovascularization in diabetic mice through stimulation of angiogenesis and arteriogenesis indicating a possible therapeutic role of this factor in ischemia-related diseases in diabetic patients.
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Shah B, Srinivas VS, Lu J, Brooks MM, Bates ER, Nedeljkovic ZS, Escobedo J, Das GS, Lopez JJ, Feit F. Change in enrollment patterns, patient selection, and clinical outcomes with the availability of drug-eluting stents in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial. Am Heart J 2013; 166:519-26. [PMID: 24016502 DOI: 10.1016/j.ahj.2013.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 05/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND In the BARI 2D trial, patients with type 2 diabetes and stable coronary artery disease were randomized to prompt revascularization versus intensive medical therapy (IMT). This analysis sought to evaluate how the availability of drug-eluting stents (DESs) has changed practice and outcomes. METHODS In BARI 2D, 1,605 patients were in the percutaneous coronary intervention (PCI)-intended stratum. As DES became available midway through recruitment, we report clinical outcomes among patients who underwent IMT versus prompt PCI with bare-metal stents (BMSs) or DES up to 4 years. RESULTS In North America, after DES became available, selection for the PCI-intended stratum increased from 73% to 79% (P = .003). Fewer BMS than DES patients had total occlusions treated or underwent rotational atherectomy (5.6% vs 9.7%, P = .02, and 1.2% vs 3.7%, P < .01, respectively). Subsequent revascularization (IMT 39%, BMS 29%, DES 21%, P < .01) and target vessel revascularization (BMS 16.1% vs DES 9.6%, P = .03) were lower with DES. Angina at 2 years tended to be less common with DES (IMT 39%, BMS 37%, DES 29%, P = .04, for 3 groups, P = .07 for DES vs BMS). The composite of death, myocardial infarction, or stroke was IMT 16.0%, BMS 20.5%, DES 17.5%; P = .80. CONCLUSIONS When DES became available in North America, patients were more likely to be selected into the PCI-intended stratum. Compared with patients receiving BMS, those receiving DES tended to have less target vessel revascularization and angina.
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Agarwal S, Bajaj NS, Zaman T, Banerjee S, Tuzcu EM, Ellis SG, Kapadia SR. Impact of diabetes on long-term mortality following multivessel percutaneous interventions: an insight into optimal statistical analysis. Int J Cardiol 2013; 167:2120-5. [PMID: 22703903 DOI: 10.1016/j.ijcard.2012.05.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 05/03/2012] [Accepted: 05/27/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Several studies have demonstrated better long-term outcomes with drug eluting stents (DES) as compared to bare metal stents (BMS) among diabetics with coronary artery disease (CAD). A significant heterogeneity exists with respect to the optimal statistical strategy to analyze stent related data. METHODS We used our percutaneous intervention (PCI) registry to identify all diabetics with CAD, who underwent PCI on two or more vessel territories between 2003 and 2009. Long-term mortality was assessed using the social security death index. Six different analytical strategies were applied. RESULTS A total of 1568 DES and 336 BMS interventions were encountered in 756 diabetics. Considerable differences were observed in the results between the methods applied. Generalized estimating equation (GEE) approach with an autoregressive correlation structure (GEE) was a robust method to account for the cluster structure, since the measurements taken through time on the same person were assumed to be highly correlated, if they were spaced more closely in time. Diabetics undergoing PCI with BMS had a significantly higher long-term mortality as compared to the patients undergoing DES-PCI [Hazard ratio (95% CI): 1.47 (1.04-2.09)]. CONCLUSION There is a great potential for erroneous interpretation of PCI data due to complex spatial and temporal clustering. Use of GEE with autoregressive correlation matrix and robust variance is most optimal to account for the clustered nature of the PCI related data. Using GEE, we observed that there is a 47% (4%-119%) higher hazard for mortality among diabetics undergoing BMS-PCI as compared to diabetics undergoing DES-PCI.
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Affiliation(s)
- Shikhar Agarwal
- Sones Cardiac Catheterization Laboratories, Heart and Vascular Institute, J2-3, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States
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Lima EG, Hueb W, Garcia RMR, Pereira AC, Soares PR, Favarato D, Garzillo CL, D’Oliveira Vieira R, Rezende PC, Takiuti M, Girardi P, Hueb AC, Ramires JA, Kalil Filho R. 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. Am Heart J 2013; 166:250-7. [PMID: 23895807 DOI: 10.1016/j.ahj.2013.04.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 04/29/2013] [Indexed: 10/26/2022]
Abstract
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.
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Calé R, Teles RC, Almeida M, do Rosário I, Sousa PJ, Brito J, Raposo L, Gonçalves PDA, Gabriel HM, Mendes M. Percutaneous coronary intervention using a full metal jacket with drug-eluting stents: major adverse cardiac events at one year. Arq Bras Cardiol 2013; 101:117-26. [PMID: 23821408 PMCID: PMC3998154 DOI: 10.5935/abc.20130139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 12/14/2013] [Indexed: 11/20/2022] Open
Abstract
Background The clinical benefit of percutaneous coronary intervention (PCI) for long coronary
lesions is unclear; furthermore, concerns have been raised about its safety. Objectives To evaluate the predictors of major adverse cardiac events (MACE) associated with
PCI using a full metal jacket (FMJ), defined as overlapping drug-eluting stents
(DES) measuring > 60 mm in length, for very long lesions. Methods We enrolled 136 consecutive patients with long coronary lesions requiring FMJ in
our single-center registry. The primary endpoint included the combined occurrence
of all-cause death, myocardial infarction (MI), and target vessel
revascularization (TVR). Demographic, clinical, angiographic, and procedural
variables were evaluated using stepwise Cox regression analysis to determine
independent predictors of outcome. Results The mean length of stent per lesion was 73.2 ± 12.3 mm and the mean reference
vessel diameter was 2.9 ± 0.6 mm. Angiographic success was 96.3%. Freedom from
MACE was 94.9% at 30 days and 85.3% at one year. At the one-year follow-up, the
all-cause mortality rate was 3.7% (1.5% cardiac deaths), the MI rate was 3.7%, and
the incidence of definite or probable stent thrombosis (ST) was 2.9%. Female
gender [hazard ratio (HR), 4.40; 95% confidence interval (CI), 1.81-10.66; p =
0.001) and non-right coronary artery PCI (HR, 3.49; 95%CI, 1.42-8.59; p = 0,006)
were independent predictors of MACE at one year. Freedom from adverse events at
one year was higher in patients with stable angina who underwent PCI (HR, 0.33;
95%CI, 0.13-0.80; p = 0.014). Conclusions PCI using FMJ with DES for very long lesions was efficacious but associated with a
high rate of ST at the one-year follow-up. However, the rate of cardiac mortality,
nonprocedure-related MI, and MACE was relatively low. Target coronary vessel PCI,
clinical presentation, and female gender are new contemporary clinical factors
that appear to have adverse effects on the outcome of PCI using FMJ for long
lesions.
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Affiliation(s)
- Rita Calé
- Mailing Address: Rita Calé, Rua João Chagas Urbanização Alto dos
Moinhos, nº4, nucleo Z 6ºEsq. Postal Code 1500-493, Lisboa, Portugal, E-mail:
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Clinical impact of second-generation everolimus-eluting stent compared with first-generation drug-eluting stents in diabetes mellitus patients: insights from a nationwide coronary intervention register. JACC Cardiovasc Interv 2013; 5:1141-9. [PMID: 23174638 DOI: 10.1016/j.jcin.2012.06.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 06/21/2012] [Indexed: 01/09/2023]
Abstract
OBJECTIVES This study sought to study the second-generation everolimus-eluting stent (EES) as compared with first-generation sirolimus-eluting (SES) and paclitaxel-eluting stents (PES) in diabetes mellitus (DM) patients. BACKGROUND There are limited data available comparing clinical outcomes in this setting with EES and SES, whereas studies comparing EES with PES are not powered for low-frequency endpoints. METHODS All DM patients treated with EES, PES, or SES from January 18, 2007, to July 29, 2011, from the SCAAR (Swedish Coronary Angiography and Angioplasty Registery) were included. The EES was compared with SES or PES for the primary composite endpoint of clinically driven detected restenosis, definite stent thrombosis (ST), and all-cause mortality. RESULTS In 4,751 percutaneous coronary intervention-treated DM patients, 8,134 stents were implanted (EES = 3,928, PES = 2,836, SES = 1,370). The EES was associated with significantly lower event rates compared with SES (SES vs. EES hazard ratio [HR]: 1.99; 95% confidence interval (CI): 1.19 to 3.08). The same was observed when compared with PES (PES vs. EES HR: 1.33; 95% CI: 0.93 to 1.91) but did not reach statistical significance. These results were mainly driven by lower incidence of ST (SES vs. EES HR: 2.87; 95% CI: 1.08 to 7.61; PES vs. EES HR: 1.74, 95% CI: 0.82 to 3.71) and mortality (SES vs. EES HR: 2.02; 95% CI: 1.03 to 3.98; PES vs. EES HR: 1.69; 95% CI: 1.06 to 2.72). No significant differences in restenosis rates were observed between EES and SES or PES (SES vs. EES HR: 1.26; 95% CI: 0.77 to 2.08; PES vs. EES HR: 1.05; 95% CI: 0.71 to 1.55). CONCLUSIONS In all-comer DM patients the use of EES was associated with improved outcomes compared with SES and PES mainly driven by lower rates of ST and mortality. These results suggest better safety rather than efficacy with EES when compared with SES or PES.
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Long-term incidence and prognostic factors of the progression of new coronary lesions in Japanese coronary artery disease patients after percutaneous coronary intervention. Heart Vessels 2013; 29:437-42. [PMID: 23807613 PMCID: PMC4085506 DOI: 10.1007/s00380-013-0382-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 06/07/2013] [Indexed: 02/02/2023]
Abstract
Revascularization of an initially non-target site due to its progression as a new culprit lesion has emerged as a new therapeutic target of coronary artery disease (CAD) in the era of drug-eluting stents. Using the Shinken database, a single-hospital-based cohort, we aimed to clarify the incidence and prognostic factors for progression of previously non-significant coronary portions after prior percutaneous coronary intervention (PCI) in Japanese CAD patients. We selected from the Shinken database a single-hospital-based cohort of Japanese patients (n = 15227) who visited the Cardiovascular Institute between 2004 and 2010 to undergo PCI. This study included 1,214 patients (median follow-up period, 1,032 ± 704 days). Additional clinically driven PCI to treat previously non-significant lesions was performed in 152 patients. The cumulative rate of new-lesion PCI was 9.5 % at 1 year, 14.4 % at 3 years, and 17.6 % at 5 years. There was no difference in background clinical characteristics between patients with and without additional PCI. Prevalence of multi-vessel disease (MVD) (82 vs. 57 %, p < 0.001) and obesity (47 vs. 38 %, p = 0.028) were significantly higher and high-density lipoprotein cholesterol (HDL) level (51 ± 15 vs. 47 ± 12 mg/dl, p < 0.001) was significantly lower in patients with additional PCI than those without. Patients using insulin (6 vs. 3 %, p = 0.035) were more common in patients with additional PCI. Multivariate analysis showed that MVD, lower HDL, and insulin use were independent determinants of progression of new culprit coronary lesions. In conclusion, progression of new coronary lesions was common and new-lesion PCI continued to occur beyond 1 year after PCI without attenuation of their annual incidences up to 5 years. Greater coronary artery disease burden, low HDL, and insulin-dependent DM were independent predictors of progression of new culprit coronary lesions.
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Kufner S, Byrne RA, Mehilli J, Massberg S, Birkmeier KA, Schulz S, Pache J, Schömig A, Kastrati A. Second-versus first-generation “Limus”-eluting stents in diabetic patients with coronary artery disease: A randomized comparison in setting of ISAR-TEST-4 trial. Catheter Cardiovasc Interv 2013; 82:E769-76. [DOI: 10.1002/ccd.24741] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 11/03/2012] [Indexed: 11/06/2022]
Affiliation(s)
| | - Robert A. Byrne
- Deutsches Herzzentrum; Technische Universität; Munich Germany
| | - Julinda Mehilli
- Deutsches Herzzentrum; Technische Universität; Munich Germany
| | | | | | - Stefanie Schulz
- Deutsches Herzzentrum; Technische Universität; Munich Germany
| | - Jürgen Pache
- Deutsches Herzzentrum; Technische Universität; Munich Germany
| | - Albert Schömig
- 1. Medizinische Klinik; Klinikum rechts der Isar; Technische Universität; Munich Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum; Technische Universität; Munich Germany
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Harskamp RE, Park DW. Optimal choice of coronary revascularization and stent type in diabetic patients with coronary artery disease. Cardiol Ther 2013; 2:69-84. [PMID: 25135290 PMCID: PMC4107438 DOI: 10.1007/s40119-013-0014-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Indexed: 01/13/2023] Open
Abstract
Patients with diabetes mellitus (DM) are prone to a diffuse and accelerated form of coronary artery disease (CAD), which in turn is a major cause of cardiac-related morbidity and mortality. Compared with patients without diabetes, patients with diabetes undergoing coronary revascularization are at higher risk of procedural, short-, and long-term cardiovascular events and mortality. Although coronary artery bypass grafting (CABG) has been regarded as the primary revascularization strategy in diabetic patients with complex CAD, percutaneous coronary intervention (PCI) is an effective revascularization alternative, due to remarkable advances in stent devices and adjunctive drug therapies. Outcomes data, from subgroup analyses and small-sized clinical trials and large registries, have suggested that PCI with current stent technology showed comparable long-term risks of mortality and hard endpoints, but higher risk of repeat revascularization for the diabetic population compared to CABG. However, the recent landmark International Future REvascularization Evaluation in patients with diabetes mellitus: optimal management of Multivessel disease (FREEDOM) trial provides compelling evidence of the superiority of CABG over PCI in reducing the rates of death, myocardial infarction, at the expense of stroke, in patients with diabetes with advanced CAD. When opting for PCI in patients with diabetes, currently used drug-eluting stents (DES) are more efficient in reducing the risk of repeat revascularization without compromising safety outcomes, compared to bare-metal stents. The selection of a specific type of DES in patients with diabetes is controversial and therefore more data comparing second- and newer-generation DES for patients with diabetes are currently needed. Also, efforts to make more advanced DES platforms suitable for patients with diabetes with complicated angiographic features are still ongoing.
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Affiliation(s)
- Ralf E Harskamp
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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80
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Woods TC. Dysregulation of the Mammalian Target of Rapamycin and p27Kip1 Promotes Intimal Hyperplasia in Diabetes Mellitus. Pharmaceuticals (Basel) 2013; 6:716-27. [PMID: 24276258 PMCID: PMC3816729 DOI: 10.3390/ph6060716] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 05/01/2013] [Accepted: 05/08/2013] [Indexed: 01/19/2023] Open
Abstract
The proliferation and migration of vascular smooth muscle cells (VSMCs) in the intima of an artery, known as intimal hyperplasia, is an important component of cardiovascular diseases. This is seen most clearly in the case of in-stent restenosis, where drug eluting stents are used to deliver agents that prevent VSMC proliferation and migration. One class of agents that are highly effective in the prevention of in-stent restenosis is the mammalian Target of Rapamycin (mTOR) inhibitors. Inhibition of mTOR blocks protein synthesis, cell cycle progression, and cell migration. Key to the effects on cell cycle progression and cell migration is the inhibition of mTOR-mediated degradation of p27Kip1 protein. p27Kip1 is a cyclin dependent kinase inhibitor that is elevated in quiescent VSMCs and inhibits the G1 to S phase transition and cell migration. Under normal conditions, vascular injury promotes degradation of p27Kip1 protein in an mTOR dependent manner. Recent reports from our lab suggest that in the presence of diabetes mellitus, elevation of extracellular signal response kinase activity may promote decreased p27Kip1 mRNA and produce a relative resistance to mTOR inhibition. Here we review these findings and their relevance to designing treatments for cardiovascular disease in the presence of diabetes mellitus.
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Affiliation(s)
- Thomas Cooper Woods
- Tulane Heart and Vascular Institute and the Department of Physiology, School of Medicine, Tulane University, 1430 Tulane Avenue, SL-48, New Orleans, LA 70112, USA.
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De Luca G, Dirksen MT, Spaulding C, Kelbæk H, Schalij M, Thuesen L, van der Hoeven B, Vink MA, Kaiser C, Musto C, Chechi T, Spaziani G, Diaz de la Llera LS, Pasceri V, Di Lorenzo E, Violini R, Suryapranata H, Stone GW. Impact of diabetes on long-term outcome after primary angioplasty: insights from the DESERT cooperation. Diabetes Care 2013; 36:1020-5. [PMID: 23275351 PMCID: PMC3609523 DOI: 10.2337/dc12-1507] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes has been shown to be associated with worse survival and repeat target vessel revascularization (TVR) after primary angioplasty. The aim of the current study was to evaluate the impact of diabetes on long-term outcome in patients undergoing primary angioplasty treated with bare metal stents (BMS) and drug-eluting stents (DES). RESEARCH DESIGN AND METHODS Our population is represented by 6,298 ST-segment elevation myocardial infarction (STEMI) patients undergoing primary angioplasty included in the DESERT database from 11 randomized trials comparing DES with BMS. RESULTS Diabetes was observed in 972 patients (15.4%) who were older (P < 0.001), more likely to be female (P < 0.001), with higher prevalence of hypertension (P < 0.001), hypercholesterolemia (P < 0.001), and longer ischemia time (P < 0.001), and without any difference in angiographic and procedural characteristics. At long-term follow-up (1,201 ± 441 days), diabetes was associated with higher rates of death (19.1% vs. 7.4%; P < 0.0001), reinfarction (10.4% vs. 7.5%; P < 0.001), stent thrombosis (7.6% vs. 4.8%; P = 0.002) with similar temporal distribution--acute, subacute, late, and very late--between diabetic and control patients, and TVR (18.6% vs. 15.1%; P = 0.006). These results were confirmed in patients receiving BMS or DES, except for TVR, there being no difference observed between diabetic and nondiabetic patients treated with DES. The impact of diabetes on outcome was confirmed after correction for baseline confounding factors (mortality, P < 0.001; repeat myocardial infarction, P = 0.006; stent thrombosis, P = 0.007; TVR, P = 0.027). CONCLUSIONS This study shows that among STEMI patients undergoing primary angioplasty, diabetes is associated with worse long-term mortality, reinfarction, and stent thrombosis in patients receiving DES and BMS. DES implantation, however, does mitigate the known deleterious effect of diabetes on TVR after BMS.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, Ospedale Maggiore della Carità, Eastern Piedmont University, Novara, Italy.
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Xu B, Yang Y, Yuan Z, Du Z, Wong SC, Généreux P, Lu S. Zotarolimus- and paclitaxel-eluting stents in an all-comer population in China: the RESOLUTE China randomized controlled trial. JACC Cardiovasc Interv 2013; 6:664-70. [PMID: 23523240 DOI: 10.1016/j.jcin.2013.03.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 03/01/2013] [Accepted: 03/04/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study sought to compare clinical outcomes and angiographic findings using the Resolute zotarolimus-eluting stent (R-ZES) (Medtronic, Santa Rosa, California) versus the Taxus Liberte paclitaxel-eluting stent (PES) (Boston Scientific, Natick, Massachusetts) in an all-comer Chinese population. BACKGROUND Concerns regarding restenosis risk led to new-generation drug-eluting stents (DES) designed for use in patients with complex clinical or lesion characteristics. In-stent late lumen loss (LLL) is a measure of restenosis risk. METHODS Patients with an indication for treatment with a DES were randomized in a 1:1 ratio to placement of at least 1 R-ZES or PES with minimal exclusions. The primary endpoint was angiographic in-stent LLL at 9 months post-procedure. Clinical endpoints at 12 months are compared between the 2 stents. RESULTS A total of 198 patients received a R-ZES, and 202 patients received a PES. Most patients were male; 25.8% and 29.2% of R-ZES and PES patients, respectively, had diabetes. Over 70% of lesions in both cohorts were American College of Cardiology/American Heart Association lesion classification Type B2 and C (B2/C). In-stent LLL was 0.16 ± 0.38 mm for R-ZES and 0.33 ± 0.52 mm for PES at 9 months (p < 0.001; 95% confidence interval [CI]: -0.26 to -0.08). The rates of clinically driven target lesion revascularization were 1.5% for R-ZES and 7.0% for PES (p = 0.011). The rate of target lesion failure was 5.6% for R-ZES and 11% for PES (p = 0.068). CONCLUSIONS In an all-comers Chinese population, 9-month in-stent LLL was significantly less with R-ZES compared with PES, which was reflected in lower revascularization rates at 12 months for the R-ZES patients. Results are consistent with previous clinical trials of the R-ZES in all-comer populations. (Resolute Zotarolimus-Eluting Stent Versus the Taxus Liberte Paclitaxel-Eluting Stent for Percutaneous Coronary Intervention in China [R-China RCT]; NCT01334268).
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Affiliation(s)
- Bo Xu
- Fu Wai Hospital, National Center for Cardiovascular Diseases of China, Beijing, China
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83
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Jang SJ, Park DW, Kim WJ, Kim YH, Yun SC, Kang SJ, Lee SW, Lee CW, Park SW, Park SJ. Differential long-term outcomes of zotarolimus-eluting stents compared with sirolimus-eluting and paclitaxel-eluting stents in diabetic and nondiabetic patients: Two-year subgroup analysis of the ZEST randomized trial. Catheter Cardiovasc Interv 2013; 81:1106-14. [DOI: 10.1002/ccd.24603] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 08/09/2012] [Indexed: 11/07/2022]
Affiliation(s)
- Sun-Joo Jang
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Duk-Woo Park
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Won-Jang Kim
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Young-Hak Kim
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Sung-Cheol Yun
- Division of Biostatistics; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Soo-Jin Kang
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Seung-Whan Lee
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Cheol Whan Lee
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Seong-Wook Park
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Seung-Jung Park
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
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Basavarajaiah S, Latib A, Hasegawa T, Rezq A, Takagi K, Naganuma T, Kawaguchi M, Figini F, Colombo A. Assessment of efficacy and safety of combining "paclitaxel" eluting balloon and "limus" eluting stent in the same lesion. J Interv Cardiol 2013; 26:259-63. [PMID: 23373592 DOI: 10.1111/j.1540-8183.2013.12010.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To assess the safety and efficacy of combining drug-eluting balloon (DEB) and drug-eluting stents (DES) in the same coronary lesion. BACKGROUND Use of DEB may not always produce optimal results or even result in dissection, compelling the operators to consider bailout stenting with bare metal stents (BMS). However, BMS may not be ideal in patients who have significant risk-profile for restenosis. We have opted for DES over BMS in such situations and present our follow-up data. METHODS Between 2009 and 2011, 46 patients (57 lesions) requiring bailout stenting following DEB use were treated with second-generation DES. All patients had at-least one or more risk-factors that made them vulnerable for restenosis (diabetes, chronic kidney disease, previous in-stent restenosis [ISR], and/or long diffuse lesions ≥ 30 mm). RESULTS Of the 57 lesions, 34 (60%) were previous ISR. The mean length of the DEB was: 36.2 ± 5.6 mm. All patients had TIMI-3 flow post PCI with no in-lab complications. At median follow-up of 12.3 months (interquartile range [IQR]: 7.5-18.1), the rates target lesion revascularization (TLR) and target vessel revascularization (TVR) were 3 (5.3%) and 4 (7%), respectively. One patient had died 3 months following treatment. There were no episodes of myocardial infarction, definite or probable stent thrombosis. The major adverse cardiovascular events (MACE) rate defined as cardiac-death, MI, and TVR occurred in 11% of patients. CONCLUSION The results from this novel strategy of combining "Paclitaxel" eluting balloon and "Limus" eluting stent in a same lesion are encouraging. Dual drug-elution acting on two different pathways may provide potential synergy that may explain the favorable outcome.
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85
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Baars T, Konorza T, Kahlert P, Möhlenkamp S, Erbel R, Heusch G, Kleinbongard P. Coronary aspirate TNFα reflects saphenous vein bypass graft restenosis risk in diabetic patients. Cardiovasc Diabetol 2013; 12:12. [PMID: 23305356 PMCID: PMC3560373 DOI: 10.1186/1475-2840-12-12] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 01/08/2013] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Patients with diabetes mellitus (DM) have an increased risk for periprocedural complications and adverse cardiac events after percutaneous coronary intervention. We addressed the potential for coronary microvascular obstruction and restenosis in patients with and without DM undergoing stenting for saphenous vein bypass graft (SVG) stenosis under protection with a distal occlusion/aspiration device. METHODS SVG plaque volume and composition were analyzed using intravascular ultrasound before stent implantation. Percent diameter stenosis was determined from quantitative coronary angiography before, immediately after and 6 months after stent implantation. Coronary aspirate was retrieved during stent implantation and divided into particulate debris and plasma. Total calcium, several vasoconstrictors, and tumor necrosis factor (TNF)α in particulate debris and coronary aspirate plasma were determined. RESULTS Patients with and without DM had similar plaque volume, but larger necrotic core and greater particulate debris release in patients with than without DM (20.3±2.7 vs. 12.7±2.6% and 143.9±19.3 vs. 75.1±10.4 mg, P<0.05). The TNFα concentration in particulate debris and coronary aspirate plasma was higher in patients with than without DM (15.9±6.6 vs. 5.1±2.4 pmol/mg and 2.2±0.7 vs. 1.1±0.2 pmol/L, P<0.05), whereas total calcium and vasoconstrictors were not different. Patients with DM had a greater percent diameter stenosis 6 months after stent implantation than those without DM (22.17±5.22 vs. 6.34±1.11%, P<0.05). The increase in TNFα immediately after stent implantation correlated with restenosis 6 months later (r=0.69, P<0.05). CONCLUSION In diabetics, particulate debris and coronary aspirate plasma contained more TNFα, which might reflect the activity of the underlying atherosclerotic process. TRIAL REGISTRATION URL: http://www.clinicaltrials.gov/ct2/results?term=NCT01430884; unique identifier: NCT01430884.
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Affiliation(s)
- Theodor Baars
- Institut für Pathophysiologie, Universitätsklinikum Essen, Hufelandstr 55, 45122 Essen, Germany
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Interventional Revascularization of Coronary Artery Lesions in Diabetic Patients; In-hospital and One Year Follow up. Int Cardiovasc Res J 2012; 6:113-7. [PMID: 24757604 PMCID: PMC3987412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 11/25/2012] [Accepted: 12/02/2012] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Diabetes mellitus is a life threatening disease accompanied by several micro- and macro vascular complications. Several modalities are available for interventional revascularization of coronary artery lesions, but their efficacy in diabetic patients is studied only in few patients. MATERIALS AND METHOD This study evaluated major in- hospital complications and clinical outcome after one year in 200 consecutive patients who underwent percutaneous Coronary Intervention from 2007 to 2009. RESULTS Our findings showed comparable single and 2 vessel stenting, regarding major adverse cardiovascular event in diabetic and nondiabetic patients. In connection with long term and in hospital outcome, no statistically significant difference was found between one and two vessel stenting when drug eluting stent was used in diabetic patients. CONCLUSION The use of drug eluting stent in single or two vessel disease of diabetic patients is technically satisfactory and clinically safe and can substitute for coronary artery bypass grafting.
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87
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Woudstra P, Damman P, Beijk MA, Grundeken MJ, Harskamp RE, Koch KT, Henriques JP, Baan J, Vis MM, Piek JJ, Tijssen JG, de Winter RJ. Clinical outcomes after bare-metal stenting in diabetic patients with lesions carrying a low risk of restenosis. Catheter Cardiovasc Interv 2012; 81:26-33. [DOI: 10.1002/ccd.24444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 04/12/2012] [Indexed: 11/08/2022]
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88
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Role of arterial stiffness and impaired renal function in the progression of new coronary lesions after percutaneous coronary intervention. Cardiovasc Interv Ther 2012; 28:56-62. [DOI: 10.1007/s12928-012-0135-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 09/13/2012] [Indexed: 10/27/2022]
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Differences in clinical and angiographic outcomes with different drug-eluting stents in Japanese patients with and without diabetes mellitus. J Cardiol 2012; 60:361-6. [PMID: 22890073 DOI: 10.1016/j.jjcc.2012.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 04/20/2012] [Accepted: 06/09/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM) is associated with worse clinical outcomes, the efficacy of drug-eluting stents (DES) in Japanese patients and differences in effectiveness between different DES types remain unknown. METHODS AND SUBJECTS Five-hundred and sixty-two consecutive patients (183 with DM, 379 without DM) with 676 lesions were treated with sirolimus-eluting stents (SES, n=531; 160 DM group, 371 non-DM group) or paclitaxel-eluting stents (PES, n=145; 64 and 81, respectively). We assessed the initial and 8-month follow-up clinical and angiographic outcomes. RESULTS There were no significant differences in clinical and lesion characteristics, although the pre-minimum luminal diameter was smaller in the DM group (p=0.016). The risk of major adverse cardiac events (MACE), defined as cardiac death, non-fatal myocardial infarction, congestive heart failure, or recurrent angina pectoris, was higher in the DM group compared with the non-DM group (17.4% vs 9.5%, p=0.007). Among diabetic patients, although SES reduced late loss by 0.45 mm (p<0.001) and the binary restenosis rate by 66.4% (7.4% vs 22.0%, p<0.001) compared with PES at 8 months, it did not reduce target lesion revascularization or MACE, as in the non-DM group. CONCLUSIONS Diabetic patients have worse mid-term prognosis than non-diabetic patients undergoing PCI with DES. Although the superiority of SES in terms of late loss or restenosis may not play a clinically meaningful role in the treatment of diabetic patients, this phenomenon was independent of the presence of diabetes.
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90
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Sato T, Ono T, Morimoto Y, Kawai H, Fuke S, Ikeda T, Saito H. Five-year clinical outcomes after implantation of sirolimus-eluting stents in patients with and without diabetes mellitus. Cardiovasc Interv Ther 2012; 27:189-95. [DOI: 10.1007/s12928-012-0115-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 06/07/2012] [Indexed: 11/30/2022]
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91
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Robertson KE, McDonald RA, Oldroyd KG, Nicklin SA, Baker AH. Prevention of coronary in-stent restenosis and vein graft failure: does vascular gene therapy have a role? Pharmacol Ther 2012; 136:23-34. [PMID: 22796519 DOI: 10.1016/j.pharmthera.2012.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 06/28/2012] [Indexed: 12/19/2022]
Abstract
Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), including stent insertion, are established therapies in both acute coronary syndromes (ACS) and symptomatic chronic coronary artery disease refractory to pharmacological therapy. These continually advancing treatments remain limited by failure of conduit grafts in CABG and by restenosis or thrombosis of stented vessel segments in PCI caused by neointimal hyperplasia, impaired endothelialisation and accelerated atherosclerosis. While pharmacological and technological advancements have improved patient outcomes following both procedures, when grafts or stents fail these result in significant health burdens. In this review we discuss the pathophysiology of vein graft disease and in-stent restenosis, gene therapy vector development and design, and translation from pre-clinical animal models through human clinical trials. We identify the key issues that are currently preventing vascular gene therapy from interfacing with clinical use and introduce the areas of research attempting to overcome these.
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Affiliation(s)
- Keith E Robertson
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Kim YG, Park DW, Lee WS, Park GM, Sun BJ, Lee CH, Hwang KW, Cho SW, Kim YR, Song HG, Ahn JM, Kim WJ, Lee JY, Kang SJ, Lee SW, Kim YH, Lee CW, Park SW, Han S, Jung SH, Choo SJ, Chung CH, Lee JW, Park SJ. Influence of diabetes mellitus on long-term (five-year) outcomes of drug-eluting stents and coronary artery bypass grafting for multivessel coronary revascularization. Am J Cardiol 2012; 109:1548-57. [PMID: 22425329 DOI: 10.1016/j.amjcard.2012.01.377] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 01/12/2012] [Accepted: 01/12/2012] [Indexed: 10/28/2022]
Abstract
Diabetes mellitus is a major risk factor for coronary artery disease (CAD) and for diffuse and progressive atherosclerosis. We evaluated the outcomes of drug-eluting stent (DES) placement and coronary artery bypass grafting (CABG) in 891 diabetic patients (489 for DES implantation and 402 for CABG) and 2,151 nondiabetic patients (1,058 for DES implantation and 1,093 for CABG) with multivessel CAD treated from January 2003 through December 2005 and followed up for a median 5.6 years. Outcomes of interest included death; the composite outcome of death, myocardial infarction (MI), or stroke; and repeat revascularization. In diabetic patients, after adjusting for baseline covariates, 5-year risk of death (hazard ratio 1.01, 95% confidence interval 0.77 to 1.33, p = 0.96) and the composite of death, MI, or stroke (hazard ratio 1.03, 95% confidence interval 0.80 to 1.31, p = 0.91) were similar in patients undergoing DES or CABG. However, rate of repeat revascularization was significantly higher in the DES group (hazard ratio 3.69, 95% confidence interval 2.64 to 5.17, p <0.001). These trends were consistent in nondiabetic patients (hazard ratio 0.80, 95% confidence interval 0.55 to 1.16, p = 0.23 for death; hazard ratio 0.77, 95% confidence interval 0.56 to 1.05, p = 0.10 for composite of death, MI, or stroke; hazard ratio 2.77, 95% CI 1.95 to 3.91, p <0.001 for repeat revascularization). There was no significant interaction between diabetic status and treatment strategy on clinical outcomes (p for interaction = 0.36 for death; 0.20 for the composite of death, MI, or stroke; and 0.40 for repeat revascularization). In conclusion, there was no significant prognostic influence of diabetes on long-term treatment with DES or CABG in patients with multivessel CAD.
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93
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Park KH, Ahn Y, Jeong MH, Chae SC, Hur SH, Kim YJ, Seong IW, Chae JK, Hong TJ, Cho MC, Bae JH, Rha SW, Jang YS. Different impact of diabetes mellitus on in-hospital and 1-year mortality in patients with acute myocardial infarction who underwent successful percutaneous coronary intervention: results from the Korean Acute Myocardial Infarction Registry. Korean J Intern Med 2012; 27:180-8. [PMID: 22707890 PMCID: PMC3372802 DOI: 10.3904/kjim.2012.27.2.180] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 08/19/2011] [Accepted: 12/22/2011] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to evaluate the impact of diabetes mellitus (DM) on in-hospital and 1-year mortality in patients who suffered acute myocardial infarction (AMI) and underwent successful percutaneous coronary intervention (PCI). METHODS Among 5,074 consecutive patients from the Korea AMI Registry with successful revascularization between November 2005 and June 2007, 1,412 patients had a history of DM. RESULTS The DM group had a higher mean age prevalence of history of hypertension, dyslipidemia, ischemic heart disease, high Killip class, and diagnoses as non-ST elevation MI than the non-DM group. Left ventricular ejection fraction (LVEF) and creatinine clearance were lower in the DM group, which also had a significantly higher incidence of in-hospital and 1-year mortality of hospital survivors (4.6% vs. 2.8%, p = 0.002; 5.0% vs. 2.5%, p < 0.001). A multivariate analysis revealed that independent predictors of in-hospital mortality were Killip class IV or III at admission, use of angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers, LVEF, creatinine clearance, and a diagnosis of ST-elevated MI but not DM. However, a multivariate Cox regression analysis showed that DM was an independent predictor of 1-year mortality (hazard ratio, 1.504; 95% confidence interval, 1.032 to 2.191). CONCLUSIONS DM has a higher association with 1-year mortality than in-hospital mortality in patients with AMI who underwent successful PCI. Therefore, even when patients with AMI and DM undergo successful PCI, they may require further intensive treatment and continuous attention.
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Affiliation(s)
- Keun-Ho Park
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Shung Chull Chae
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Seung Ho Hur
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Young Jo Kim
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - In Whan Seong
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Jei Keon Chae
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Taek Jong Hong
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Myeong Chan Cho
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Jang Ho Bae
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Seung Woon Rha
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Yang Soo Jang
- Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
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Long-term clinical and angiographic outcomes of diabetic patients after revascularization with early generation drug-eluting stents. Am Heart J 2012; 163:876-886.e2. [PMID: 22607867 DOI: 10.1016/j.ahj.2012.02.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 02/19/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND Early generation drug-eluting stents (DESs) reduce restenosis and repeat revascularization procedures. However, the long-term safety and efficacy of early generation DES according to diabetic status are poorly established. METHODS A total of 1,012 patients were randomly assigned to treatment with sirolimus-eluting (n = 503) or paclitaxel-eluting stents (n = 509). Serial angiographic follow-up at baseline, 8 months, and 5 years was available in 293 patients with 382 lesions. The primary end point was a composite of major adverse cardiac events (cardiac death, myocardial infarction, and ischemia-driven target lesion revascularization). Clinical and angiographic outcomes through 5-year follow-up were compared between diabetic and nondiabetic patients. RESULTS Major adverse cardiac events were more common among diabetic than nondiabetic patients at 5 years (25.9% vs 19.2%, hazard ratio [HR] 1.45, 95% CI 1.06-1.99, P = .02). The difference in disfavor of diabetic patients was largely determined by a higher rate of cardiac mortality (11.4% vs 4.3%, HR 2.86, 95% CI 1.69-4.84, P < .0001), whereas the risk of myocardial infarction (6.5% vs 6.8%, HR 1.00, 95% CI 0.55-1.84, P = .99) and ischemia-driven target lesion revascularization (14.4% vs 14.1%, HR 1.09, 95% CI 0.73-1.64, P = .67) was comparable. The risk of stent thrombosis was similar among diabetic and nondiabetic patients (definite or probable: 6.0% vs 4.6%, HR 1.36, 95% CI 0.71-2.67, P = .35). Among 293 patients undergoing serial angiography, very-late lumen loss amounted to 0.42 ± 0.63 mm in diabetic patients and 0.44 ± 0.68 mm in nondiabetic patients (P = .79). CONCLUSIONS Diabetic patients remain at increased risk for mortality after revascularization with early generation DES during long-term follow-up. Conversely, diabetes is no longer associated with an increased risk of clinical and angiographic restenosis after revascularization with early generation DES.
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Laynez A, Sardi G, Hauville C, Barbash IM, Pakala R, Torguson R, Xue Z, Satler LF, Pichard AD, Waksman R. Safety and efficacy of everolimus-eluting stents versus paclitaxel-eluting stents in a diabetic population. Catheter Cardiovasc Interv 2012; 81:759-65. [PMID: 22488756 DOI: 10.1002/ccd.24438] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 03/01/2012] [Accepted: 03/27/2012] [Indexed: 11/05/2022]
Abstract
OBJECTIVES This study aimed to analyze the use of everolimus-eluting stents (EES) and paclitaxel-eluting stents (PES) in an unrestricted diabetic population and to compare the performance of these two drug-eluting stents. BACKGROUND EES have demonstrated superiority in efficacy when compared to PES in a general population. However, it is controversial whether this superiority holds true in a diabetic population. METHODS From March 2004 to May 2010, 968 patients with consecutive diabetes who underwent percutaneous coronary intervention and implantation of an EES (n = 388) or PES (n = 580) at our institution. In-hospital, 1-month, 6-month, and 1-year clinical outcomes were analyzed and compared. Correlates of major adverse cardiac events (MACE) were identified. RESULTS Baseline clinical characteristics were similar between stent types except for more family history of coronary artery disease in the PES group and more insulin-dependent diabetes and unstable angina at initial diagnosis in the EES group. The PES group had higher number of lesions treated, longer stents used, and a higher proportion of intravascular ultrasound and glycoprotein IIb/IIIa inhibitor use. The EES group had more type C and distal lesions. There was higher target lesion revascularization (TLR)-MACE in the PES group (3.3% vs. 1.0%, P = 0.03) as well as a higher rate of stent thrombosis (ST) (8 patients vs. 0 in the EES group, P = 0.03). ST continued to be higher in the PES group at 6 and 12 months and mortality was higher at 12 months in the PES group (9.4% vs. 5.2%, P = 0.02). After adjustment, no significant differences were found between stent types on Cox regression analysis for hazard ratios at 1-year follow-up of TLR-MACE. CONCLUSIONS In a diabetic population undergoing PCI, the use of an EES compared to PES was associated with lower rates of stent thrombosis; but after adjustment the composite TLR-MACE at 1 year was similar between both stents.
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Affiliation(s)
- Ana Laynez
- Department of Cardiology, Washington Hospital Center, Washington, District of Columbia 20010, USA
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96
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Ng VG, Lansky AJ. The Generations of Drug-Eluting Stents and Outcomes in Women. Interv Cardiol Clin 2012; 1:183-195. [PMID: 28582092 DOI: 10.1016/j.iccl.2012.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Drug-eluting stents have become one of the mainstays of percutaneous coronary artery revascularization. Since their introduction, there have been many developments in this technology including the optimization of the stent platform, novel polymer coatings, and antiproliferative drugs. Although cardiovascular disease is the leading cause of death in women, the prevalence of obstructive coronary artery disease is lower, and women comprise a minority of patients included in clinical trials assessing the performance of drug-eluting stents. This article reviews the advances in drug-eluting stent technology and the studies reporting outcomes in women after implantation of these stents.
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Affiliation(s)
- Vivian G Ng
- Columbia University Medical Center, Medical Housestaff Office, 177 Fort Washington Avenue, 6th Floor, Room 12, New York, NY 10032, USA
| | - Alexandra J Lansky
- Yale University School of Medicine, PO Box 208017, New Haven, CT 06520-8017, USA.
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Sinning JM, Baumgart D, Werner N, Klauss V, Baer FM, Hartmann F, Drexler H, Motz W, Klues H, Voelker W, Pfannebecker T, Stoll HP, Nickenig G. Five-year results of the Multicenter Randomized Controlled Open-Label Study of the CYPHER Sirolimus-Eluting Stent in the Treatment of Diabetic Patients with De Novo Native Coronary Artery Lesions (SCORPIUS) study: a German multicenter investigation on the effectiveness of sirolimus-eluting stents in diabetic patients. Am Heart J 2012; 163:446-53, 453.e1. [PMID: 22424016 DOI: 10.1016/j.ahj.2011.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Accepted: 12/12/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND Because a delayed arterial healing response after drug-eluting stent implantation has raised concerns about safety in diabetic patients, long-term effects of treatment with sirolimus-eluting stent (SES), as compared with bare-metal stent (BMS), have to be established. The aim of the 5-year follow-up of the randomized, controlled, open-label multicenter SCORPIUS study was to assess long-term safety and efficacy of the CYPHER (Cordis, Johnson & Johnson, Bridgewater, NJ) SES in percutaneous coronary intervention of diabetic patients. METHODS A total of 190 patients with type 2 diabetes mellitus were randomized to receive either a SES (n = 95) or a BMS (n = 95). Dual-antiplatelet therapy (aspirin plus clopidogrel) was prescribed for at least 6 months. Clinical follow-up data were scheduled at 1, 8, and 12 months and 5 years. RESULTS Treatment with SES resulted in a 16% decrease in the rate of major adverse cardiac events (36% vs 52%; hazard ratio 0.6, 95% CI 0.4-0.9; P = .02). This reduction in major adverse cardiac events with SES at 5 years was mostly attributable to a lower number of repeat target lesion revascularization (13% vs 29%; hazard ratio 0.4, 95% CI 0.2-0.7; P = .003). No differences between groups were observed for safety end points (all-cause mortality 21% vs 21%, cardiac death 15% vs 13%, repeat myocardial infarction 8% vs 9%, and stent thrombosis 5% vs 6%) at 5 years. CONCLUSIONS The 5-year follow-up of the SCORPIUS trial demonstrates the long-term antirestenotic efficacy of SES in diabetic patients with significantly reduced target lesion revascularization and comparable rates of mortality, myocardial infarction, and stent thrombosis compared with BMS.
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What the radiologist needs to know about the diabetic patient. Insights Imaging 2012; 2:193-203. [PMID: 22347947 PMCID: PMC3259362 DOI: 10.1007/s13244-011-0068-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 11/16/2010] [Accepted: 01/13/2011] [Indexed: 12/13/2022] Open
Abstract
Diabetes mellitus (DM) is recognised as a major health problem. Ninety-nine percent of diabetics suffer from type 2 DM and 10% from type 1 and other types of DM. The number of diabetic patients worldwide is expected to reach 380 millions over the next 15 years. The duration of diabetes is an important factor in the pathogenesis of complications, but other factors frequently coexisting with type 2 DM, such as hypertension, obesity and dyslipidaemia, also contribute to the development of diabetic angiopathy. Microvascular complications include retinopathy, nephropathy and neuropathy. Macroangiopathy mainly affects coronary arteries, carotid arteries and arteries of the lower extremities. Eighty percent of deaths in the diabetic population result from cardiovascular incidents. DM is considered an equivalent of coronary heart disease (CHD). Stroke and peripheral artery disease (PAD) are other main manifestations of diabetic macroangiopathy. Diabetic cardiomyopathy (DC) represents another chronic complication that occurs independently of CHD and hypertension. The greater susceptibility of diabetic patients to infections completes the spectrum of the main consequences of DM. The serious complications of DM make it essential for physicians to be aware of the screening guidelines, allowing for earlier patient diagnosis and treatment.
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99
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Vasaiwala S, Mauri L. Clinical review of the Resolute®zotarolimus-eluting stent for the treatment of coronary artery disease. Interv Cardiol 2012. [DOI: 10.2217/ica.11.85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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100
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Natarajan MK, Strauss BH, Rokoss M, Buller CE, Mancini GBJ, Xie C, Sheth TN, Goodhart D, Cohen EA, Seidelin P, Harper W, Gerstein HC. Randomized trial of insulin versus usual care in reducing restenosis after coronary intervention in patients with diabetes. the STent Restenosis And Metabolism (STREAM) study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2012; 13:95-100. [PMID: 22296781 DOI: 10.1016/j.carrev.2011.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 12/04/2011] [Accepted: 12/08/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Diabetes status is an independent marker of restenosis after percutaneous coronary intervention (PCI). Previous studies suggest that metabolic abnormalities associated with diabetes increase stent restenosis by promoting intimal hyperplasia. Preclinical studies have indicated that insulin therapy reduces intimal hyperplasia. The objective of this study was to determine whether insulin-mediated glucose lowering reduces in-stent restenosis in patients with diabetes undergoing PCIs. METHODS We conducted a prospective, randomized, multicenter, open-labeled study with blinded outcomes. Patients were randomized 1:1 to daily bedtime subcutaneous NPH insulin (Novo Nordisk) versus usual therapy with oral hypoglycemic agents. The main outcomes were change in volume of intimal hyperplasia within the stent measured by intravascular ultrasound and late lumen loss by quantitative coronary angiography at 6 months post-PCI. RESULTS Seventy-eight patients (36 insulin, 42 usual care) were randomized. Eight patients in each group received drug-eluting stents. The insulin group achieved greater reductions in both glycosylated hemoglobin A1c (mean±S.D.) (insulin: 8.0%±1.2% to 6.7%±0.7% vs. control: 7.5%±1.2% to 7.1%±1.0 %, P=.0038) and fasting glucose (insulin: 9.3±3.8 to 5.8±1.7 vs. usual care: 8.4±2.4 to 7.7±2.0 mmol/l, P<.0001). There were no hypoglycemic events. At 6 months, there were no significant differences in either intravascular-ultrasound-determined neointimal volume (insulin: 41.2±38.9 vs. usual care: 48.4±40.2 mm(3), P=.33) or late lumen loss by angiography (insulin: 1.29±0.74 mm vs. usual care: 1.02±0.71 mm, P=.17). CONCLUSIONS Addition of a single bedtime dose of insulin in patients with diabetes does not influence in-stent restenosis.
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Affiliation(s)
- Madhu K Natarajan
- Division of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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