How to revascularize patients with diabetes mellitus: bypass or stents and drugs?

Sirolimus eluting stent (Cypher) in patients with diabetes mellitus: results from the German Cypher Stent Registry

BACKGROUND

Patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) are at increased risk for adverse outcomes. The use of sirolimus eluting stents (SES) has been shown to improve outcomes in diabetic patients. Since results from randomized trials were derived from selected patients scientific scrutiny under real world conditions is necessary.

METHODS AND RESULTS

1,948 patients with DM and 4,707 patients without DM were included in the German Cypher Registry, a post-marketing survey of use of SES in Germany. In >99% of entry cases a structured clinical follow-up was completed. By angiographic criteria severity of coronary artery disease was higher in diabetic patients compared to non-diabetics. However, procedural success and in-hospital complication rates were comparable between DM- and non-DM-patients. 6 months MACE rate in the DM group was significantly higher than in the non-DM group (16.4% vs. 13.0%) but lower than expected from historical data with the use of bare metal stents (BMS).

CONCLUSION

The results with SES in diabetics are encouraging but DM remains a risk factor for poor outcome of PCI. No statement is justified whether the treatment of diabetics with SES is at least as safe as bypass surgery. This intriguing question has to be answered in a direct randomized head-to-head comparison with state of the art surgery.

The Paclitaxel-Eluting Coroflex™ Please Stent Pilot Study (PECOPS I)

BACKGROUND

The alleged superiority of drug-eluting stents over bare metal devices and those with passive coatings is diminished by a higher incidence of late target vessel thrombosis.

METHODS AND RESULTS

Therefore, the one-year clinical outcome of the paclitaxel-eluting Coroflex Please stent in patients with denovo coronary lesions was evaluated in the single-arm PECOPS I pilot study. The clinical data of 96/97 (99%) of the patients included per protocol and of 86/87 (98.9%) of those treated per protocol were available 13.1 +/- 1.8 months following stent deployment. In the inclusion and treatment per protocol groups the incidence of cardiac deaths was 1/96 (1%) and 1/86 (1.2%), of myocardial infarction 3/96 (3.1%) and 1/86 (1.2%), and of target lesion revascularization 9/96 (9.4%) and 8/86 (9.3%). In patients enrolled per protocol two early thromboses (2.1%) occurred one of which two days after premature discontinuation of clopidogrel. In patients treated per protocol one thrombosis was observed after 10 hours. The one-year event-free survival was 83/96 (86.5%) in patients enrolled per protocol and 75/86 (87.2%) in those treated per protocol.

CONCLUSION

The one-year clinical outcome of PECOPS I was within the range of other paclitaxel-eluting coronary stents. The relative small number of patients enrolled in PECOPS I precludes to infer any further conclusions.

In vitro evaluation of coronary stents and in-stent stenosis using a dynamic cardiac phantom and a 64-detector row CT scanner

INTRODUCTION

The aim of the study was to examine the ability of a 64-slice MDCT to detect in-stent stenoses in an ex vivo model of coronary stents.

METHODS

Five different stents (Liberté, Boston Scientific; Driver, Medtronic; Multi-Link Vision, Guidant; Taxus Express, Boston Scientific; Cypher, Cordis) were examined using a dynamic cardiac phantom. The stents were pulled over a vessel model that consists of a polymer tube with diameters of 3.0, 3.5, and 4.0 mm and four different degrees of stenoses (0%; 30%; 50%; 70-80%). This model was moved with a rate of 60 bpm to mimic cardiac motion. To assess the degree of artificial signal reduction (artificial reduction of attenuation (ARA)) by the different stents, attenuation values were measured in the vessel outside the stent, and in the non-stenotic vessel inside the stent. Furthermore the grade of stenosis was assessed by two clinical observers.

RESULTS

Highest ARA was found for the Cypher Stent (35 HU), whereas the Liberté Stent presented the lowest ARA (16 HU). Depending on the stent and the vessel diameter, up to 87.5% of the stenoses were correctly diagnosed. In the 3.0 and 3.5 mm vessels, a nonstenotic or low-grade stenotic vessel was diagnosed as intermediate or high-grade stenosis in 22.5%, whereas in the 4.0 mm vessels, this kind of overestimation did not occur. A 50% stenosis was diagnosed as a 30% stenosis in 30%. On the other hand, high-grade stenoses were underestimated in only 10%. On a four-point scale, the average deviation from the real grade of stenosis was 0.21 for the Liberté stent, 0.54 for the Taxus Express stent, 0.29 for Driver stent, 0.62 for the Multi-Link Vision stent, and 0.37 for the Cypher stent.

CONCLUSIONS

In a dynamic cardiac phantom model, high grade stenoses in vessels with a diameter of 4 mm could be reliably detected irrespective of the stent type used in this study. Vice versa, high grade stenoses (> or = 50%) could only be ruled out with certainty in vessels with a diameter of 4 mm. In smaller vessels, the ability to correctly diagnose high-grade stenoses was dependent on the type of stent and the imaging artifacts associated with it.

The role of SOAT-1 polymorphisms in cognitive decline and delirium after bypass heart surgery

BACKGROUND

Cognitive decline (CD) and delirium (PD) are commonly observed complications after bypass heart surgery. In this study we aimed to investigate whether certain genetic factors (alleles of the SOAT-1 gene) play a role in their appearance.

PATIENTS AND METHODS

We examined 137 patients receiving coronary bypass surgery with a neuropsychiatric test battery consisting of the Mini Mental State Examination (MMSE), the Brief Psychiatric Rating Scale (BPRS), the Wechsler's Memory Scale-Revised (WMS-R) on admission and one month after surgery, and the Delirium Rating Scale postoperatively, when indicated, and genotyped them in relation to the SOAT-1 genotypes (AA positive group with augmented protection of the nerve cells against stress and the AA negative group--AC and CC subgroups--with diminished protection against stress).

RESULTS

We noted a significant decline in test results postoperatively and a high frequency of delirium (29.92% of the patients). None of these complications could be associated to the SOAT-1 genotypes.

CONCLUSIONS

Our study confirmed the expected cognitive decline and highly frequent delirium after bypass heart surgery and excluded the possible role of SOAT-1 genotype polymorphisms in their genesis.

Incidence and predictors of target vessel revascularization after sirolimus-eluting stent treatment for proximal left anterior descending artery stenoses among 2274 patients fromthe prospectivemulticenter German Cypher Stent Registry

BACKGROUND

Involvement of the proximal LAD is considered an indication for coronary artery bypass graft (CABG) surgery due to the high restenosis rates associated with this location after percutaneous coronary interventions (PCI). This seems to be different, however, when using sirolimus-eluting stents, a finding if proven to be true could have a major impact on clinical decision making regarding the optimal revascularization strategy for these patients.

METHODS

We analyzed 2274 patients treated for proximal LAD stenoses using SES from the German Cypher Stent Registry. The incidence of TVR and other major clinical adverse events were determined and independent predictors of TVR were specified using a multiple logistic regression model.

RESULTS

Event-free survival was achieved in 89.5% of patients. TVR was performed in 179 patients (7.9%) and the combined incidence of all cause death, myocardial infarction and TVR was 10.5% (231 patients). Independent predictors of TVR were multivessel disease (OR 1.74, 95% CI 1.16-2.62, p = 0.008), stent diameter < or = 2.75 mm (OR 1.61, 95% CI 1.10-2.40, p = 0.02) and the administration of GP IIb/ IIIa antagonists (OR 1.60, 95% CI 1.05-2.60, p = 0.03). TVR rate was as high as 11.2% for 2.5 mm SES and as low as 4.0% for 3.5 mm SES (p < 0.001 for trend test).

CONCLUSION

TVR among patients treated with SES for proximal LAD stenoses is low and is related in part to operator dependent factors. Treatment with SES should be considered as an effective treatment for these patients.