Percutaneous Coronary Intervention in Patients With Insulin-Treated and Non-Insulin-Treated Diabetes Mellitus: Secondary Analysis of the TUXEDO Trial

Effects of percutaneous coronary intervention and diabetes mellitus on short- and long-term prognosis assessed by the three-vessel quantitative flow ratio

AIMS

We aimed to investigate the impact of percutaneous coronary intervention (PCI) and diabetes mellitus (DM) on short- and long-term prognosis in patients with coronary artery disease using three-vessel quantitative flow ratio (3 V-QFR) assessment.

METHODS

A retrospective analysis of 2440 vessels in 1181 patients who underwent PCI was performed. The patients were categorized according to the presence or absence of DM and the median 3 V-QFR. The primary outcome was the occurrence of major adverse cardiac events (MACE), defined as a combination of cardiovascular death, myocardial infarction, and ischemia-driven revascularization, over a 5-year period.

RESULTS

The pre-PCI and post-PCI 3 V-QFR values for the entire population were 2.37 (2.04-2.56) and 2.94 (2.82-3.00), respectively. Landmark analysis showed that the incidence of MACE was comparable among all groups within the first year (log-rank p = 0.088). Over the course of 2 years, the incidence of MACE was higher in both groups with a post-PCI 3 V-QFR < 2.94 (log-rank p < 0.001). However, from 2 to 5 years, patients with DM had higher rates of MACE (log-rank p = 0.013).

CONCLUSIONS

In the short term, a low post-PCI 3 V-QFR is a predictor of high risk for MACE. However, in the long term, DM emerges as the dominant risk factor.

Influence of Race/Ethnicity and Sex on Coronary Stent Outcomes in Diabetic Patients

Background

How diabetes mellitus (DM), race/ethnicity, and sex impact ischemic events following coronary artery stent procedures is unknown.

Methods

Using the PLATINUM Diversity and PROMUS Element Plus Post-Approval Pooled Study (N = 4184), we examined the impact of race/ethnicity, sex, and DM on coronary stent outcomes. Primary outcome was 1-year major adverse cardiac events (MACE) (MACE composite: death, myocardial infarction [MI], and target vessel revascularization).

Results

The study sample included 1437 diabetic patients (501 White men, 470 White women, 246 minority men, 220 minority women) and 2641 patients without medically treated DM (561 minority, 1090 women). Mean age (years) ranged from 61 in minority men to 65 in White women. Diabetic patients had a higher prevalence of atherosclerotic risk factors and comorbidities. Diabetic minority women (DMW; 70% Black, 27% Hispanic) had similar atherosclerotic risk factors to other diabetics, but experienced higher 1-year MACE (14.4% vs 7.5%, P <.01) and MI (4.3% vs 1.6%, P <.01) rates compared with patients without medically treated DM. No other diabetic cohort (White men, White women, minority men) showed an increased risk of MACE vs patients without medically treated DM. The incremental risk of MACE in DMW was associated with insulin use and persisted after risk adjustment (adjusted odds ratio 1.6 vs patients without medically treated DM; 95% CI, 1.0-2.5). Independent predictors of 1-year MACE included insulin use, hyperlipidemia, renal disease, and prior MI.

Conclusions

DMW face the highest risk of ischemic events following coronary stenting, driven, in part, by insulin use. Aggressive secondary prevention and strict glycemic control are imperative in this cohort, and further research is warranted to elucidate the biologic mechanisms underpinning these observations.

Clinical Trial Registration

NCT02240810 (http://clinicaltrials.gov/).

Rationale and design of the TUXEDO-2 India study: Ultra-Thin strUt Supraflex Cruz versus XiencE in a Diabetic pOpulation with multi-vessel disease-2

BACKGROUND

The role of percutaneous coronary interventions (PCI) in patients with diabetes mellitus and multi-vessel disease has been questioned by the results of the FREEDOM trial, which showed superiority of coronary artery bypass graft(CABG) over first generation drug-eluting stents (DES) including a reduction in mortality. In the light of safer and more efficacious stents and significantly better medical management, those results that date back to 2012 need to be revisited. TUXEDO-2 is a study designed to compare two contemporary stents in Indian diabetic patients with multi-vessel disease.

AIMS

The primary objective of the TUXEDO-2 study is to compare the clinical outcomes of PCI with ultra-thin Supraflex Cruz vs Xience when combined with contemporary optimal medical therapy (OMT) in diabetic patients with multi-vessel disease. The secondary objective is to compare clinical outcomes between a pooled cohort from both arms of the study (Supraflex Cruz + Xience; PCI arm) vs CABG based on a performance goal derived from the CABG arm of the FREEDOM trial (historical cohort). The tertiary objective is a randomized comparison of ticagrelor vs prasugrel in addition to aspirin for the composite of ischemic and bleeding events.

METHODS

In this prospective, open-label, multi-centre, 2 × 2 factorial, randomized, controlled study, 1,800 patients with diabetes mellitus and multi-vessel disease (inclusion criteria similar to FREEDOM trial) with indication for coronary revascularization will be randomly assigned to Supraflex Cruz or Xience stents and also to ticagrelor- or prasugrel- based antiplatelet strategies. All patients will receive guideline directed OMT and optimal PCI including image- and physiology-guided complete revascularization where feasible. The patients will be followed through five years to assess their clinical status and major clinical events. The primary endpoint is a non-inferiority comparison of target lesion failure at one-year for Supraflex Cruz vs Xience (primary objective) with an expected event rate of 11% and a non-inferiority margin of 4.5%. For PCI vs CABG (secondary objective), the primary endpoint is major adverse cardiac events (MACE), defined as a composite of all cause death, nonfatal myocardial infarction, or stroke at one-year and yearly up to five years, with a performance goal of 21.6%. For ticagrelor vs prasugrel (tertiary objective), the primary endpoint is composite of death, myocardial infarction, stroke, and major bleeding as per the Bleeding Academic Research Consortium (BARC) at one-year with expected event rate of 15% and a non-inferiority margin of 5%.

CONCLUSIONS

The TUXEDO-2 study is a contemporary study involving state-of-the-art PCI combined with guideline directed OMT in a complex subset of patients with diabetes mellitus and multi-vessel disease. The trial will answer the question as to whether a biodegradable polymer coated ultra-thin Supraflex Cruz stent is an attractive option for PCI in diabetic patients with multi-vessel disease. It will also help address the question whether the results of FREEDOM trial would have been different in the current era of safer and more efficacious stents and modern medical therapy. In addition, the comparative efficacy and safety of ticagrelor vs prasugrel in addition to aspirin will be evaluated. (CTRI/2019/11/022088).

Percutaneous coronary intervention in insulin-treated diabetic patients: A meta-analysis

Background

This meta‐analysis of randomized controlled trials (RCTs) compared long‐term adverse clinical outcomes of percutaneous coronary intervention (PCI) in insulin‐treated diabetes mellitus (ITDM) and non‐ITDM patients.

Methods

This is a meta‐analysis study. The PubMed and Embase databases were searched for articles on long‐term adverse clinical outcomes of PCI in ITDM and non‐ITDM patients. The risk ratios (RR) and 95% confidence intervals (CI) were calculated.

Results

A total of 11 related RCTs involving 8853 DM patients were included. Compared with non‐ITDM patients, ITDM patients had significantly higher all‐cause mortality (ACM) (RR = 1.52, 95% CI: 1.25–1.85, p_{heterogeneity} = .689, I² = 0%), major adverse cardiac and cerebrovascular events (MACCE) (RR = 1.35, 95% CI: 1.18–1.55, p_{heterogeneity} = .57, I² = 0%), myocardial infarction (MI) (RR = 1.41, 95% CI: 1.16–1.72, p_{heterogeneity} = .962, I² = 0%), and stent thrombosis (ST) (RR = 1.75, 95% CI: 1.23–2.48, p_{heterogeneity} = .159, I² = 32.4%). No significant difference was found in the target lesion revascularization (TLR) and target vessel revascularization (TVR) between the ITDM and non‐ITDM groups.

Conclusions

The results showed that ITDM patients had significantly higher ACM, MACCE, MI, and ST, compared with non‐ITDM patients.

Short- and long-term cardiovascular outcomes in insulin-treated versus non-insulin-treated diabetes mellitus patients after percutaneous coronary intervention: A systematic review and meta-analysis

Aims

This study aims to assess differences in severity of short-term (<1 year) and long-term (≥1 year) adverse CV outcomes after PCI in insulin-treated vs. non-insulin-treated diabetes mellitus (DM) patients.

Methods

A systematic search on Pubmed and Embase led to the incorporation of 29 studies that compared post-percutaneous coronary interventional outcomes in insulin-treated and non-insulin-treated diabetes mellitus. Diabetes mellitus (type 2) was defined as fasting blood glucose (FBG) level of >7.0 mmol/L or with an oral glucose tolerance test (OGTT) level of >11.1 mmol/L at least on two separate occasions. Adverse CV outcomes were assessed in insulin-treated and non-insulin-treated DM after the PCI procedure considered for the analyses were mortality, MACE, TLR, TVR, MI, stent thrombosis, target lesion failure (TLF), and need for-post PCI CABG. Data were pooled and analyzed using Review Manager 5.3, and risk ratios (RR) with respective 95% confidence intervals (CI) were calculated.The statistical analyses were carried out by Review Manager v.5.3, and the data were pooled using a random-effects model. Risk ratios (RRs) with 95% confidence intervals (CI) were reported along with forest plots. The chi-square test was performed to assess for differences between the subgroups. Heterogeneity across studies was evaluated using Higgins I² statistics. Visual inspection of the funnel plot and Begg's regression test were used to assess publication bias.

Results

A total of 40,527 patients (11742 in the Insulin-treated diabetes mellitus group and 28785 in the non-insulin-treated DM group) who underwent PCI were included. The pooled analysis of short-term follow up outcomes preceding PCI demonstrated a significantly higher risk of mortality (RR = 1.75 [1.24,2.47]; p = 0.002), MI (RR = 1.81[1.14,2.87]; p = 0.01], stent thrombosis (RR = 1.63[1.13, 2.35]; p = 0.009) and target lesion revascularization (TLR) (RR = 1.29[1.02,1.63]; p = 0.03) in insulin-treated DM patients. Similarly, analysis of long-term follow-up studies depicted a significantly higher risk mortality (RR = 1.55 [1.22, 1.97]; p = 0.0003), MI (RR = 1.63 [1.35, 1.97]; p=<0.00001), MACE (R = 1.47 [1.31, 1.65]; p=<0.00001), stent thrombosis (RR = 1.54 [1.19,1.99]; p = 0.001), TLR (RR = 1.40 [1.18, 1.66]; p = 0.0001), target vessel revascularization (TVR) (RR = 1.35 [1.11, 1.64]; p = 0.003) in insulin-treated DM group after PCI versus non-insulin-treated DM patients.

Conclusion

Despite a tremendous technical success rate of multi-vessel stenting, people living with diabetes who were being treated with insulin had higher long-term, and short-term mortality rates, MI, TLR, TVR, and stroke compared to people living with diabetes who were being treated with means other than insulin and are more prone to detrimental cardiovascular outcomes.

Outcomes of Participants With Diabetes in the ISCHEMIA Trials

BACKGROUND

Among patients with diabetes and chronic coronary disease, it is unclear if invasive management improves outcomes when added to medical therapy.

METHODS

The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trials (ie, ISCHEMIA and ISCHEMIA-Chronic Kidney Disease) randomized chronic coronary disease patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, hemoglobin A1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with versus without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease severity or left ventricular function).

RESULTS

Of 5900 participants with complete baseline data, the median age was 64 years (interquartile range, 57-70), 24% were female, and the median estimated glomerular filtration was 80 mL·min^-1·1.73^-2 (interquartile range, 64-95). Among the 2553 (43%) of participants with diabetes, the median percent hemoglobin A1c was 7% (interquartile range, 7-8), and 30% were insulin-treated. Participants with diabetes had a 49% increased hazard of death or MI (hazard ratio, 1.49 [95% CI, 1.31-1.70]; P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI, 0.48-0.60) and 0.66 (95% bootstrapped CI, 0.61-0.71) for patients with diabetes versus without diabetes, respectively, with a 12% (95% bootstrapped CI, 4%-20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI, 0.42-0.56) and 0.49 (95% bootstrapped CI, 0.42-0.56), respectively. There was no difference in death or MI between strategies for patients with diabetes versus without diabetes, or for clinical (female sex or insulin use) or anatomic features (coronary artery disease severity or left ventricular function) of patients with diabetes.

CONCLUSIONS

Despite higher risk for death or MI, chronic coronary disease patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

Differential impact of type 1 and type 2 diabetes mellitus on outcomes among 1.4 million US patients undergoing percutaneous coronary intervention

BACKGROUND

The aim was to determine the impact of diabetes mellitus (DM) on outcomes after percutaneous coronary intervention (PCI). There is limited data on the impact of DM and its subtypes among patients who underwent PCI during hospitalization.

METHODS

All PCI hospitalizations from the National Inpatient Sample (October 2015-December 2018) were stratified by the presence and subtype of DM. Multivariable logistic regression was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in type 1 DM (T1DM) and type 2 DM (T2DM) compared to no-DM.

RESULTS

Out of 1,363,800 individuals undergoing PCI, 12,640 (0.9%) had T1DM and 539,690 (39.6%) had T2DM. T1DM patients had increased aOR of major adverse cardiovascular and cerebrovascular events (MACCE) (1.26, 95%CI 1.17-1.35), mortality (1.56, 95%CI 1.41-1.72), major bleeding (1.63, 95%CI 1.45-1.84), and stroke (1.75, 95%CI 1.51-2.02), while T2DM patients had only increased aOR of MACCE (1.02, 95%CI 1.01-1.04), mortality (1.10, 95%CI 1.08-1.13) and stroke (1.22, 95%CI 1.18-1.27), compared to no-DM patients. However, both T1DM and T2DM had lower aOR of cardiac complications (0.87, 95%CI 0.77-0.97 and 0.87, 95%CI 0.85-0.89, respectively), in comparison to no-DM patients. When accounting for the indication, both DM subgroups had higher aOR of MACCE, mortality, and stroke compared to no-DM patients in the acute coronary syndrome setting (p < 0.001, for all), while only increased aOR of stroke (1.59, 95%CI 1.17-2.15 for T1DM and 1.12, 95%CI 1.05-1.20 for T2DM) persisted in the elective setting.

CONCLUSIONS

Patients with DM who have undergone PCI during hospitalization are more likely to experience adverse in-hospital outcomes, and T1DM patients are a particularly high-risk cohort.

Comparison of Long-Term Outcomes After Percutaneous Coronary Intervention in Patients With Insulin-Treated Versus Non-Insulin Treated Diabetes Mellitus

There are conflicting data on whether patients with insulin-treated diabetes mellitus (ITDM) have poorer outcomes compared with non-insulin treated diabetic (non-ITDM) patients following percutaneous coronary intervention (PCI). We therefore compared clinical outcomes following PCI in ITDM versus non-ITDM patients. We prospectively collected data on 4,579 patients with diabetes underwent PCI between 2005 and 2014 in a large multicenter registry and dichotomized them as having ITDM (n = 1,111) or non-ITDM (n = 3,468). The non-ITDM group was further divided into diet control only (diet-DM; n = 786) and those taking oral hypoglycemic agents (OHG-DM; n = 2,639), and clinical outcomes were compared with ITDM patients. Median follow-up for long-term mortality was 4.2 years (IQR 2.0 to 6.6 years). ITDM patients were more likely to be female, obese, and have severe renal impairment (all p <0.001). Procedural characteristics were similar other than a greater use of drug-eluting stents in ITDM patients. On multivariable analysis, ITDM was an independent predictor of 12-month major adverse cardiovascular and cerebrovascular events (MACCE; OR 1.26, 95% CI 1.02 to1.55, p = 0.03). Dividing the non-ITDM group further by treatment, a progressively higher rate of 12-month MACCE across the 3 groups was observed (13.5% vs 17.9% vs 21.8%; p <0.001). Long-term mortality was similar in the diet-DM and OHG-DM groups, but significantly higher in the ITDM group on Kaplan-Meier analysis (log-rank p <0.001). In conclusion, there is a clear gradient of adverse outcomes with escalation of therapy from diet control to OHGs to insulin.

Targeting "diabetic" coronary stenosis merging the properties of sirolimus coated balloon with sirolimus eluting stent

BACKGROUND

Patients with diabetes mellitus (DM) represents a challenging subset of population as they experience worse outcomes after percutaneous coronary intervention than patients without diabetes. We evaluated the 2-year efficacy and safety profile of the Abluminus DES+ in patients with diabetes within the population enrolled in the large multicenter en-ABL e-registry.

METHODS

Multicenter, prospective, all-comers registry performed in 31 centers in India. We analyze patients according to the diagnosis of DM and insulin dependency (ID or Non-ID): non-DM (1.641 patients), NIDDM (721 patients), IDDM (138 patients). The primary endpoint was a composite of device-oriented major adverse cardiac events (MACE): cardiac death, target vesselrelated myocardial infarction (MI), and ischemia-driven target lesion revascularization (TLR)/ target vessel revascularization (TVR) at 2-year. Stent thrombosis (ST) at any time point was also recorded.

RESULTS

The MACE rate at 2-year follow-up was 3.0 %in the overall population with DM patients showing a higher rate of primary endpoint compared to non-DM (4.4 % vs 2.4 %, p=0.025). Rate of cardiac death was actually low and consistent between the 2 groups (1.7 % vs 0.9 %, p=0.100). At 2-year, the rate of ST was 0.9 % in DM patients versus 0.5 % in non-DM, p=0.213.

CONCLUSIONS

At 2-year, the Abluminus DES+ technology that merges the features of a sirolimus coated balloon with those of a bioresorbable polymer drug eluting stent appears to be safe and effective. This safety/efficacy profile was consistent in patients with or without DM.

Effect of Glycemic Control During Follow-up on Late Target Lesion Revascularization After Implantation of New-Generation Drug-Eluting Stents in Patients With Diabetes - A Single-Center Observational Study

Background: Few studies have investigated the importance of glycemic control in patients with diabetes mellitus (DM) for reducing the incidence of late target lesion revascularization (TLR) after implantation of new-generation drug-eluting stents (DES).

Methods and Results: We retrospectively identified 1,568 patients who underwent new-generation DES implantation. Patients were divided into 3 groups based on diabetic status and glycemic control 1 year after the procedure: those without DM (non-DM group; n=1,058) and those with DM at follow-up with either good (HbA1c <7%; n=328) or poor (HbA1c ≥7%; n=182) control. The cumulative 5-year incidence of clinically driven late TLR after the index procedure was significantly higher in DM with poor control at follow-up than in those with good control at follow-up or non-DM (14%, 4.8%, and 2.9%, respectively; P<0.0001). Multivariate analysis revealed that poor control at follow-up was significantly associated with a higher risk of clinically driven late TLR compared with the non-DM group (hazard ratio [HR] 4.58, 95% confidence interval [CI] 2.50–8.16, P<0.0001). However, good control at follow-up group was not associated with a higher risk of clinically driven late TLR compared with the non-DM group (HR 1.35, 95% CI 0.68–2.56, P=0.38).

Conclusions: DM patients with poor glycemic control at follow-up had a significantly higher risk of clinically driven late TLR than non-DM patients.

Association Between Hemoglobin A1c and Major Adverse Coronary Events in Patients with Diabetes Following Coronary Artery Bypass Surgery

INTRODUCTION

Diabetes is associated with a higher risk of major adverse coronary events (MACE) following coronary artery bypass grafting (CABG). Guidelines recommend disparate targets for glycemic control of patients with diabetes who have undergone CABG, ranging from a target hemoglobin A1c (HbA1c) of < 7.0% to 7.1-8.5%, based on data from non-CABG patients. To date, no study has evaluated the long-term impact of HbA1c concentrations on MACE post-CABG.

OBJECTIVE

To evaluate the association between HbA1c and MACE in CABG patients with diabetes.

METHODS

A secondary analysis of the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI2D) trial, which enrolled patients with type 2 diabetes and coronary artery disease, restricted to participants who underwent CABG with ≥ 1 HbA1c measurement post-CABG, was performed. The index date was date of first post-CABG HbA1c measurement. The primary outcome was MACE (composite of death, myocardial infarction, unstable angina, or repeat revascularization). Secondary outcomes included MACE components and heart failure. Cox proportional hazards models treating HbA1c as a time-dependent exposure (reference group: HbA1c 6.1-7.0%) were used to derive hazard ratios (HRs) with 95% confidence intervals adjusting for age, sex and baseline characteristics selected by stepwise regression.

RESULTS

A total of 549 patients were followed over a median 3.5 years. The median age of the cohort was 64 years, 25.1% were female, and median baseline HbA1c was 6.7%. Compared to achieving an HbA1c 6.1-7.0%, HbA1c > 8.0% was associated with an increased risk of MACE (HR 1.77, 1.01-3.10). This association was strongest for unstable angina (HR 5.21, 1.03-26.39). Achieving an HbA1c ≤ 6.0% was associated with an increased risk of death (HR 2.41, 1.01-5.74). Other comparisons were not statistically significant.

CONCLUSION

Among patients with type 2 diabetes who underwent CABG, achieving HbA1c 6.1-7.0% was associated with a lower risk of MACE and unstable angina versus achieving an HbA1c > 8.0% and lower risk of death versus achieving an HbA1c ≤ 6.0%.

Impact of Insulin-Treated and Noninsulin-Treated Diabetes Mellitus in All-Comer Patients Undergoing Percutaneous Coronary Interventions With Polymer-Free Biolimus-Eluting Stent (from the RUDI-FREE Registry)

Patients with diabetes mellitus (DM) have worse outcomes after percutaneous coronary intervention (PCI). Recent evidences suggest a differential impact of insulin-treated and noninsulin-treated DM on prognosis. We evaluated the clinical outcome of diabetic patients after PCI with polymer-free biolimus-eluting stent from the RUDI-FREE Registry, investigating a possible different prognostic impact of insulin-treated and noninsulin-treated DM. A total of 1,104 consecutive patients who underwent PCI with polymer-free biolimus-eluting stent, enrolled in the RUDI-FREE observational, multicenter, single-arm registry, were stratified by diabetic status; diabetic population was further divided on the basis of insulin treatment. Primary end points of the study were target lesion failure (TLF; composite of cardiac death, target vessel myocardial infarction, target lesion revascularization) and major adverse cardiac and cerebrovascular events (composite of cardiac death, stroke, and myocardial infarction). Multiple ischemic adverse events were also single-handedly considered as secondary end points. At 1 year, TLF was significantly higher in the diabetic cohort, as compared with nondiabetic patients (6.0% vs 3.1%, p 0.022). None of the end points resulted significantly different between nondiabetics and noninsulin-treated diabetic patients. Divergently, compared with nondiabetic, insulin-treated diabetic patients faced significant higher rates of TLF (10.8% vs 3.1%, p 0.003), major adverse cardiac and cerebrovascular events (10.8% vs 3.4%, p 0.004), and of most of the analyzed adverse events. In conclusion, patients with DM had a higher risk of TLF compared with nondiabetics; nonetheless, the worse outcome of the diabetic population seems to be driven by the insulin-treated diabetic subpopulation. This finding suggests a different risk profile of insulin-treated and noninsulin-treated diabetic patients in the modern era of PCI.

Short-Term Versus Long-Term Adverse Cardiovascular Outcomes Post Percutaneous Coronary Intervention in Patients with Insulin-Treated Type 2 Diabetes Mellitus: A Simple Meta-Analysis

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a major health issue, especially in patients with coexisting coronary artery disease (CAD). Patients with insulin-treated T2DM (ITDM) have worse outcomes than those with non-insulin-treated T2DM. Very few studies have compared short-term to long-term adverse cardiovascular outcomes following percutaneous coronary intervention (PCI) in patients on insulin therapy. Therefore, in this meta-analysis, we systematically compared short-term to long-term adverse cardiovascular outcomes in a population of patients with ITDM following PCI.

METHODS

We searched for English-language publications focusing on PCI in patients with ITDM using specific search terms/phrases. All the participants accepted for inclusion in this meta-analysis were treated with a drug-eluting stent. Post-intervention adverse cardiovascular outcomes observed during short-term and long-term follow-up periods were assessed and compared. Statistical analysis was carried out using the popular RevMan 5.3 software. Odd ratios (OR) with 95% confidence intervals (CI) were calculated.

RESULTS

Six studies comprising 1568 participants with ITDM in total were included in this simple meta-analysis. Patient enrollment periods varied but enrollment occurred during the years 1993-2012. When a fixed-effects statistical model was used, post-PCI adverse cardiovascular outcomes-such as major adverse cardiac events (MACEs) (OR 3.33, 95% CI 2.64-4.21; P = 0.00001), all-cause mortality (OR 5.73, 95% CI 3.37-9.73; P = 0.00001), myocardial infarction (MI) (OR 1.47, 95% CI 1.05-2.07; P = 0.02), and repeated revascularization (OR 4.78, 95% CI 3.29-6.94; P = 0.00001)-were found to be significantly more likely during the long-term follow-up period. A similar result was observed with a random-effects statistical model.

CONCLUSION

Adverse cardiovascular outcomes post PCI were significantly more likely during the long-term follow-up period than during the short-term follow-up period in these patients with T2DM on insulin therapy. This hypothesis requires confirmation via new comparative trials that consider short-term and long-term follow-up periods.

Impact of Diabetes Mellitus in Women Undergoing Percutaneous Coronary Intervention With Drug-Eluting Stents

BACKGROUND

Data examining the impact of diabetes mellitus (DM) on ischemic risk after percutaneous coronary intervention in women are limited as most clinical trial participants are male. We evaluated (1) the impact of DM on ischemic outcomes in women undergoing drug-eluting stent (DES) implantation and (2) whether the outcomes of new- versus early-generation DES vary by DM status.

METHODS AND RESULTS

We pooled patient-level data of 10 448 women undergoing percutaneous coronary intervention with DES from 26 randomized trials. Baseline characteristics and 3-year clinical outcomes were stratified according to DM status (noninsulin-dependent and insulin-dependent) and DES generation. The primary end point was the composite of all-cause death or myocardial infarction. Secondary end points were definite or probable stent thrombosis and target lesion revascularization. Compared with women without DM (n=7154, 68.5%), adjusted risks (adjusted hazard ratios [95% CI]) for death or myocardial infarction among women with noninsulin-dependent DM (n=2241, 21.4%) and insulin-dependent DM (n=1053, 10.1%) were 1.30 (1.11-1.53) and 1.71 (1.41-2.07), respectively ( P_trend<0.001). Similar trends were observed for def/prob stent thrombosis and target lesion revascularization. Compared with early-generation DES, use of newer-generation DES was associated with significant reductions in death or myocardial infarction in the absence of DM whereas differences were nonsignificant in the presence of DM, with similar findings for def/prob stent thrombosis and target lesion revascularization.

CONCLUSIONS

The presence of DM is associated with substantial, graded, and durable risks for ischemic events among women undergoing percutaneous coronary intervention with DES. The safety and efficacy profile of newer-generation DES is preserved among women without DM, while benefits are nonsignificant among women with DM.

Outcomes in Patients with Diabetes Mellitus According to Insulin Treatment After Percutaneous Coronary Intervention in the Second-Generation Drug-Eluting Stent Era

Limited data exist regarding the clinical outcomes of patients with diabetes mellitus (DM) after percutaneous coronary intervention (PCI) using second-generation drug-eluting stents (DES), especially according to DM treatment. The purpose of this study was to compare clinical outcomes among patients without DM, with non-insulin-treated DM (non-ITDM), and with ITDM after PCI using second-generation DES. We analyzed 4,812 consecutive patients who underwent PCI using second-generation DES. Primary outcomes were patient-oriented composite outcome (a composite of all-cause mortality, any myocardial infarction, and any revascularization) at 3 years. Among the total population, 3,026 patients have no DM, 1,169 have non-ITDM, and 617 have ITDM. Patients with DM, regardless of non-ITDM and ITDM, showed significantly higher risk of patient-oriented composite outcome (21.0% vs 14.5%; adjusted hazard ratio [HR_adj]1.41, 95% confidence interval [CI] 1.19 to 1.66, p <0.001), mainly driven by significantly higher risk of cardiac death and any revascularization compared with non-DM. Among DM population, ITDM showed significantly higher risk of cardiac death (7.7% vs 3.7%; HR_adj 1.97, 95% CI 1.19 to 3.27, p = 0.009), any revascularization (17.0% vs 11.4%; HR_adj 1.40, 95% CI 1.01 to 1.93, p = 0.041), and definite/probable stent thrombosis (1.7% vs 0.7%; HR_adj 2.80, 95% CI 1.04 to 7.56, p = 0.042) compared with non-ITDM. In conclusion, even in the era of second-generation DES, patients with DM are at significantly higher risk of patient-oriented adverse events. Among these, patients with ITDM showed the highest risk of adverse events, mainly driven by higher risk of mortality, any revascularization, and definite/probable stent thrombosis.

Revascularization for patients with diabetes mellitus and stable ischemic heart disease: an update

PURPOSE OF REVIEW

To provide an update on the management of patients with diabetes mellitus and requiring coronary revascularization.

RECENT FINDINGS

Evidence continues to show that patients with diabetes mellitus and ischemic heart disease represent a very high-risk group of patients. Choice of stent appears important for minimizing target lesion and target vessel adverse events with everolimus eluting stents having the best performance, particularly in patients being treated with insulin. The higher risk of adverse angioplasty results in patients with diabetes appears most related to the disease state per se and not necessarily to anatomical complexities. Interestingly, physiologic documentation of nonischemia producing lesions with use of fractional flow reserve appears less reassuring in this setting of aggressive and rapid atherosclerosis progression, particularly if myocardial infarction has occurred previously, than in patients without diabetes. Coronary artery bypass surgery in patients with appropriate anatomy and diabetes continues to emerge in many analyzes as the optimal, long-term therapy.

IMPLICATIONS

The treatment of diabetes per se, advances in stent technology and optimization of coronary artery bypass techniques are all occurring in parallel making it very critical for the design of modern era trials that keep pace with these advances. Currently, in patients with appropriate anatomy who are willing candidates, bypass surgery remains the optimal, long-term therapeutic option.

Cardiac Versus Non-Cardiac Related Mortality Following Percutaneous Coronary Intervention in Patients with Insulin-Treated Type 2 Diabetes Mellitus: A Meta-Analysis

INTRODUCTION

Cardiovascular mortality is a major concern for patients with type 2 diabetes mellitus (T2DM). Insulin therapy significantly contributes to a high rate of death in these patients. We have performed a meta-analysis comparing cardiac and non-cardiac-related mortality following percutaneous coronary intervention (PCI) in a sample of patients with insulin-treated type 2 diabetes mellitus (ITDM).

METHODS

Studies were included in the meta-analysis if: (1) they were trials or cohort studies involving patients with T2DM post-PCI; (2) the outcomes in ITDM were separately reported; and (3) they reported cardiac death and non-cardiac death among their clinical endpoints. ITDM patients with any degree of coronary artery disease were included. The analysis was carried out using RevMan version 5.3 software, and data were reported with odds ratios (OR) and 95% confidence intervals (CI) as the main parameters.

RESULTS

A total of 4072 participants with ITDM were included, of whom 1658 participants and 2414 participants were extracted from randomized controlled trials and observational cohorts, respectively. Analysis of all data showed that death due to cardiac causes was significantly higher in patients with ITDM (OR 2.16, 95% CI 1.79-2.59; P = 0.00001). At 1 year of follow-up, cardiac death was still significantly higher compared to non-cardiac death (OR 2.39, 95% CI 1.47-3.88; P = 0.0004), and this result did not change with a longer follow-up period (3-5 years) (OR 2.09, 95% CI 1.70-2.56; P = 0.00001). Death due to cardiac causes was still significantly higher in the subpopulations of patients with everolimus-eluting stents (OR 2.31, 95% CI 1.26-4.26; P = 0.007), paclitaxel-eluting stents (OR 2.36, 95% CI 1.63-3.39; P = 0.00001), sirolimus-eluting stents (OR 2.11, 95% CI 1.67-2.67; P = 0.00001), and zotarolimus-eluting stents (OR 2.12, 95% CI 1.11-4.05; P = 0.02), respectively.

CONCLUSIONS

Mortality due to cardiac causes was significantly higher than that due to non-cardiac causes in patients with ITDM who had undergone PCI. The same conclusion could be drawn from analyses focused on different follow-up periods, types of coronary stents, and type of study data used.

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

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

Prognostic Relation Between Severity of Diabetes Mellitus (On or Off Insulin) ± Chronic Kidney Disease with Cardiovascular Risk After Percutaneous Coronary Intervention

The presence of either diabetes mellitus (DM) or chronic kidney disease (CKD) is associated with a worse prognosis after percutaneous coronary intervention (PCI). It is also known that outcomes in patients treated with insulin (insulin requiring type 2 diabetes mellitus [ITDM]) are worse than those who are not on insulin (non-insulin type 2 diabetes mellitus [NITDM]). We sought to compare long-term outcomes in patients who underwent PCI with varying severity of DM with and without CKD. We retrospectively studied 17,898 patients who underwent PCI from January 2009 to December 2014 in the Mount Sinai Cath Lab. Patients were categorized into groups by the presence or the absence of CKD and by the DM status (none, NITDM, or ITDM). In the absence of CKD, adjusted hazard ratios (95% confidence interval [CI]) for death or myocardial infarction associated with NITDM and ITDM were 1.65 (95% CI 1.02 to 2.67) and 3.78 (95% CI 2.23 to 6.40), respectively. Analogous risks in the presence of CKD were 3.34 (95% CI 1.99 to 5.61) and 6.26 (95% CI 3.84 to 10.2). This study shows that irrespective of renal status, the need for insulin in the setting of DM identifies a group with substantial risk of death or myocardial infarction at 1 year.

Coronary Stents in Diabetic Patients: State of the Knowledge

PURPOSE OF REVIEW

This review article aims to summarize the findings of the most relevant research that compared the use of paclitaxel vs. "limus" based drug eluting stent (DES) in diabetic patients and to define the current state of knowledge with new stent technologies in this patient population.

RECENT FINDINGS

Since drug eluting stents (DES) were introduced, it has been of great interest to establish whether paclitaxel or sirolimus eluting stents have the same safety and efficacy features for patients with coronary artery disease. The answer to this question is particularly relevant for diabetic patients. Several randomized trials, registry-based studies, and meta-analyses have assessed the performance of these different DES in diabetic patients. The most recently published data favors limus over paclitaxel DES in diabetic patients, but most of these studies compared first vs. second generation DES with the inherent caveats of comparing different platforms, alloys, and drug delivery vehicles. In this literature review, we found that there is robust evidence favoring the use of DES over bare metal stents in diabetic patients with coronary artery disease. We also found that the current state of knowledge is that the everolimus eluting stents have better safety and efficacy than paclitaxel eluting stents in diabetic patients and hence should be the preferred choice. New revascularization strategies including bio-absorbable scaffolds, polymer free stents, and bio-degradable polymers are being studied in diabetic patients with encouraging results.

Percutaneous coronary interventions in diabetics: The never-ending challenge

Diabetes mellitus (DM) is a multisystem disorder and a recognized risk factor for coronary artery disease (CAD) and DM patient are particularly challenging for revascularization. In this "real world" retrospective study post-PCI DM patients showed a high risk profile compared to the non-DM group, given by the higher prevalence of cardiovascular risk factors, multiple vessel disease, and renal dysfunction, with the highest rates seen in the ITDM. Only ITDM patients present higher 30-day mortality compared to non-DM patients in the urgent and primary PCI setting. Also ITDM, but not those NITDM patients, had an increased long-term mortality in the overall cohort and in all PCI setting.