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Liu Y, Liu JE, He H, Qin M, Lei H, Meng J, Liu C, Chen X, Luo W, Zhong S. Characterizing the metabolic divide: distinctive metabolites differentiating CAD-T2DM from CAD patients. Cardiovasc Diabetol 2024; 23:14. [PMID: 38184583 PMCID: PMC10771670 DOI: 10.1186/s12933-023-02102-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/25/2023] [Indexed: 01/08/2024] Open
Abstract
OBJECTIVE To delineate the metabolomic differences in plasma samples between patients with coronary artery disease (CAD) and those with concomitant CAD and type 2 diabetes mellitus (T2DM), and to pinpoint distinctive metabolites indicative of T2DM risk. METHOD Plasma samples from CAD and CAD-T2DM patients across three centers underwent comprehensive metabolomic and lipidomic analyses. Multivariate logistic regression was employed to discern the relationship between the identified metabolites and T2DM risk. Characteristic metabolites' metabolic impacts were further probed through hepatocyte cellular experiments. Subsequent transcriptomic analyses elucidated the potential target sites explaining the metabolic actions of these metabolites. RESULTS Metabolomic analysis revealed 192 and 95 significantly altered profiles in the discovery (FDR < 0.05) and validation (P < 0.05) cohorts, respectively, that were associated with T2DM risk in univariate logistic regression. Further multivariate regression analyses identified 22 characteristic metabolites consistently associated with T2DM risk in both cohorts. Notably, pipecolinic acid and L-pipecolic acid, lysine derivatives, exhibited negative association with CAD-T2DM and influenced cellular glucose metabolism in hepatocytes. Transcriptomic insights shed light on potential metabolic action sites of these metabolites. CONCLUSIONS This research underscores the metabolic disparities between CAD and CAD-T2DM patients, spotlighting the protective attributes of pipecolinic acid and L-pipecolic acid. The comprehensive metabolomic and transcriptomic findings provide novel insights into the mechanism research, prophylaxis and treatment of comorbidity of CAD and T2DM.
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Affiliation(s)
- Yingjian Liu
- School of Medicine, South China University of Technology, Guangzhou, 510006, Guangdong, China
- Department of Pharmacy, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan 2nd Road, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong, China
| | - Ju-E Liu
- Department of Pharmacy, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Huafeng He
- School of Medicine, South China University of Technology, Guangzhou, 510006, Guangdong, China
- Department of Pharmacy, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan 2nd Road, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong, China
| | - Min Qin
- School of Medicine, South China University of Technology, Guangzhou, 510006, Guangdong, China
- Department of Pharmacy, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan 2nd Road, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong, China
| | - Heping Lei
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong, China
| | - Jinxiu Meng
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong, China
| | - Chen Liu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoping Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China
| | - Wenwei Luo
- Department of Pharmacy, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan 2nd Road, Guangzhou, 510080, China.
| | - Shilong Zhong
- School of Medicine, South China University of Technology, Guangzhou, 510006, Guangdong, China.
- Department of Pharmacy, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan 2nd Road, Guangzhou, 510080, China.
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong, China.
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Long term outcomes of percutaneous coronary intervention vs coronary artery bypass grafting in patients with diabetes mellitus with multi vessels diseases: A meta-analysis. IJC HEART & VASCULATURE 2023; 46:101185. [DOI: 10.1016/j.ijcha.2023.101185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 01/25/2023] [Accepted: 02/05/2023] [Indexed: 02/27/2023]
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Ahmed A, Varghese KS, Fusco PJ, Mathew DM, Mathew SM, Ahmed S, Rogando DO, Salazar SA, Pandey R, Awad AK, Levy KH, Hernandez M, Calixte R. Coronary Revascularization in Patients With Diabetes: A Meta-Analysis of Randomized Controlled Trials and Propensity-Matched Studies. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:29-40. [PMID: 36628960 DOI: 10.1177/15569845221143420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Patients with diabetes have poorer outcomes with coronary artery disease (CAD) and pose a unique clinical population for revascularization. We performed a pairwise meta-analysis of randomized trials (RCTs) and propensity-matched observational studies (PMS) to compare the clinical outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with diabetes. METHODS A comprehensive literature search was performed to identify RCT and PMS studies comparing CABG with PCI in patients with diabetes with concurrent CAD. Studies were pooled using the random-effects model to perform a pairwise meta-analysis. Primary outcomes included long-term all-cause mortality, cardiac mortality, myocardial infarction (MI), major adverse cardiac and cerebrovascular events (MACCE), and repeat revascularization. Meta-regression was used to explore the effects of baseline risk factors on primary outcomes with moderate to high heterogeneity. RESULTS A total of 18 RCTs and 9 PMS with 28,846 patients were included. PCI was associated with increased long-term all-cause mortality (risk ratio [RR] = 1.34, P < 0.001), cardiac mortality (RR = 1.52, P < 0.001), MI (RR = 1.51, P = 0.009), MACCE (RR = 1.65, P < 0.001), and repeat revascularization (RR = 2.48, P < 0.001) compared with CABG. There was no difference in long-term stroke between the 2 groups (RR = 0.95, P = 0.82). At meta-regression, a greater proportion of female patients in studies was associated with a decreased protective benefit for CABG for long-term all-cause mortality but an increased protective benefit for long-term MI and repeat revascularization. CONCLUSIONS Revascularization of patients with diabetes using CABG is associated with significantly reduced long-term mortality, MI, MACCE, and repeat revascularizations. Future studies exploring the influence of gender on revascularization outcomes are necessary to elucidate the ideal treatment modality in patients with diabetes.
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Affiliation(s)
- Adham Ahmed
- City University of New York School of Medicine, New York, NY, USA
| | | | - Peter J Fusco
- City University of New York School of Medicine, New York, NY, USA
| | - Dave M Mathew
- City University of New York School of Medicine, New York, NY, USA
| | - Serena M Mathew
- City University of New York School of Medicine, New York, NY, USA
| | - Sarah Ahmed
- City University of New York School of Medicine, New York, NY, USA
| | - Dillon O Rogando
- City University of New York School of Medicine, New York, NY, USA
| | | | - Roshan Pandey
- City University of New York School of Medicine, New York, NY, USA
| | - Ahmed K Awad
- City University of New York School of Medicine, New York, NY, USA
| | - Kenneth H Levy
- City University of New York School of Medicine, New York, NY, USA
| | | | - Rose Calixte
- Epidemiology and Biostatistics, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
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Nicolas J, Pivato CA, Chiarito M, Beerkens F, Cao D, Mehran R. Evolution of drug-eluting coronary stents: a back-and-forth journey from the bench-to-bedside. Cardiovasc Res 2022; 119:631-646. [PMID: 35788828 DOI: 10.1093/cvr/cvac105] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Coronary stents have revolutionized the treatment of coronary artery disease. Compared with balloon angioplasty, bare-metal stents effectively prevented abrupt vessel closure but were limited by in-stent restenosis due to smooth muscle cell proliferation and neointimal hyperplasia. The first-generation drug-eluting stent (DES), with its antiproliferative drug coating, offered substantial advantages over bare-metal stents as it mitigated the risk of in-stent restenosis. Nonetheless, they had several design limitations that increased the risk of late stent thrombosis. Significant advances in stent design, including thinner struts, enhanced polymers' formulation, and more potent antiproliferative agents, have led to the introduction of new-generation DES with a superior safety profile. Cardiologists have over 20 different DES types to choose from, each with its unique features and characteristics. This review highlights the evolution of stent design and summarizes the clinical data on the different stent types. We conclude by discussing the clinical implications of stent design in high-risk subsets of patients.
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Affiliation(s)
- Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carlo Andrea Pivato
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy.,IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy.,IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Frans Beerkens
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Cardiovascular Department, Humanitas Gavazzeni, Bergamo, Italy
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Arabi A, Naghshtabrizi B, Baradaran HR, Moradi Y, Asadi-Lari M, Mehrakizadeh A. Comparing clinical outcomes in patients with diabetes undergoing coronary artery bypass graft and percutaneous coronary intervention in real world practice in Iranian population. BMC Cardiovasc Disord 2022; 22:75. [PMID: 35240990 PMCID: PMC8895790 DOI: 10.1186/s12872-022-02521-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 02/23/2022] [Indexed: 11/18/2022] Open
Abstract
Background Coronary artery bypass graft (CABG) is generally regarded as one the treatment options for coronary artery disease (CAD) in patients with diabetes. In recent years, with the advent of drug-eluting stents (DES), percutaneous coronary intervention (PCI) was introduced as a suitable alternative for CABG. The aim of this study was to compare the incidence of major adverse cardiac and cerebrovascular event (MACCE) during mid-term period in patients with diabetes treated with 2 revascularization strategies. Methods This historical cohort study was conducted on 750 consecutives patients with diabetes in a single cardiovascular center from July 2009 to March 2012 in Iran. We included previously known case of DM treated with antidiabetic medications (with or without end organ damage) and patient with preoperational evaluation FBS test > 126 (not on the day of the surgery) who were revascularized by 2 strategies. We excluded those patients whose follow-up was not possible. Results Finally, out of 697 eligible patients, 355 patients underwent a CABG and 342 underwent a PCI: 53 patients were lost to follow-up (27 in CABG and 26 in PCI groups). The mean follow-up time was 900.68 ± 462.03 days in the CABG and 782.60 ± 399.05 in PCI groups. There were 17 (9.13%) cardiac deaths in the CABG group and 8 (4.45%) in the PCI group; this difference was not significant (P = .11). There was 14 (7.58%) cerebrovascular accident in the CABG group and 4 (2.31%) in the PCI group; this difference was significant (P = .04). Moreover, the frequency of the target vessel revascularization in the CABG and PCI groups was 6 (3.32%) and 31 (17.11%) (P < .001), respectively. Myocardial infarction in the CABG group was 5 (2.77%) and 14 (7.86%) in the PCI group (P = .009). Finally, the frequency of MACCE in the CABG and PCI groups was 41(20.70%) and 47(24.16%) respectively; this difference was not statistically significant (P = .195). Conclusion Patients with CABG in this study experienced more CVA, while the frequency of TVR and non-fatal MI was higher in the PCI arm.
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Affiliation(s)
- Arezo Arabi
- Department of Cardiology, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran
| | - Behshad Naghshtabrizi
- Department of Cardiology, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran
| | - Hamid Reza Baradaran
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran.,Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Yousef Moradi
- Department of Epidemiology and Biostatistics, Faculty of Medicine, Kurdistan University of Medical Sciences, Kurdistan, Iran
| | - Mohsen Asadi-Lari
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran.
| | - Ali Mehrakizadeh
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Scudeler TL, Godoy LC, Hoxha T, Kung A, Moreno PR, Farkouh ME. Revascularization Strategies in Patients with Diabetes and Acute Coronary Syndromes. Curr Cardiol Rep 2022; 24:201-208. [PMID: 35089503 DOI: 10.1007/s11886-022-01646-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW To review the current evidence for coronary revascularization in patients with diabetes mellitus (DM) in the setting of an acute coronary syndrome (ACS). RECENT FINDINGS In patients with DM and stable multivessel ischemic heart disease, coronary artery bypass graft surgery (CABG) has been observed to be superior to percutaneous coronary intervention (PCI) in long-term follow-up, leading to lower rates of all-cause mortality, myocardial infarction, and repeat revascularization. In the ACS setting, PCI remains the most frequently performed procedure. In patients with an ST-segment-elevation myocardial infarction (STEMI), primary PCI should be the revascularization method of choice, whenever feasible. Controversy still exists regarding when and how to deal with possible residual lesions. In the non-ST-segment-elevation (NSTE) ACS setting, although there are no data from randomized controlled trials (RCTs), recent observational data and sub-analyses of randomized studies have suggested that CABG may be the preferred approach for patients with DM and multivessel coronary disease. There is a paucity of RCTs evaluating revascularization strategies (PCI and CABG) in patients with DM and ACS. CABG may be a viable strategy, leading to improved outcomes, especially following NSTE-ACS.
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Affiliation(s)
- Thiago L Scudeler
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Lucas C Godoy
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada
| | - Tedi Hoxha
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Andrew Kung
- American University of the Caribbean School of Medicine, St. Maarten, US
| | - Pedro R Moreno
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, US
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada.
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Liang B, He X, Gu N. Reassessing Revascularization Strategies in Coronary Artery Disease and Type 2 Diabetes Mellitus. Front Cardiovasc Med 2021; 8:738620. [PMID: 34746255 PMCID: PMC8568070 DOI: 10.3389/fcvm.2021.738620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/16/2021] [Indexed: 01/11/2023] Open
Abstract
Percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is still controversial in patients with coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM). Here, we aimed to evaluate the long-term follow-up events of PCI and CABG in these populations. Relevant randomized controlled trials were retrieved from PubMed, Embase, and the Cochrane databases. The pooled results were represented as risk ratios (RRs) with 95% confidence intervals (CIs) with STATA software. A total of six trials with 1,766 patients who received CABG and 2,262 patients who received PCI were included in our study. Patients in the CABG group were significantly associated with a lower all-cause mortality compared with those in the PCI group (RR = 0.74, 95% CI = 0.56–0.98, P = 0.037). Cardiac mortality, recurrent myocardial infarction, and repeat revascularization were also significantly lower in the CABG group (RR = 0.79, 95% CI = 0.40–1.53, P = 0.479; RR = 0.70, 95% CI = 0.32–1.56, P = 0.387; and RR = 0.36, 95% CI = 0.28–0.46, P < 0.0001; respectively). However, compared with the PCI group, the cerebral vascular accident was higher in the CABG group (RR = 2.18, 95% CI = 1.43–3.33, P < 0.0001). There was no publication bias in our study. CABG revascularization was associated with significantly lower long-term adverse clinical outcomes, except cerebral vascular accident, compared with PCI in patients with CAD and T2DM. Systematic Review Registration: PROSPERO, identifier: CRD42020216014.
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Affiliation(s)
- Bo Liang
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Xin He
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Ning Gu
- Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
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Akın H, Bilge Ö. Relationship between frontal QRS-T duration and the severity of coronary artery disease in who were non-diabetic and had stable angina pectoris. Anatol J Cardiol 2021; 25:572-578. [PMID: 34369885 DOI: 10.5152/anatoljcardiol.2021.33232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE There is a known relationship between frontal-QRS-T (F-QRS-T) angle and coronary artery disease (CAD). This study examined the relationship between F-QRS-T angle changes and CAD severity in patients with stable CAD. METHODS A total of 202 patients were included in the study after the implementation of exclusion criteria among 894 patients, who were admitted to the outpatient clinic with stable angina pectoris between September 2018 and September 2019. The F-QRS-T angle calculated on the 12-lead electrocardiograms (ECGs) of the patients (taken in the outpatient clinic), and the CAD severity calculated using the Gensini score in patients undergoing coronary angiography were compared. RESULTS Of the patients included in the study, 38.6% were female and 61.4% were male. The mean age was calculated as 60.16±11.27 years, and 52% of the patients had hypertension. There was no difference between the groups in terms of demographic and clinical values. In a comparison of CAD severity and F-QRS-T angles, the F-QRS-T angle was seen to be statistically significantly higher in the severe CAD group [91°° (102/79)] compared to the group with mild CAD [53°° (64/38)]. In the multivariate logistic regression analysis, there was a significant association between the F-QRS-T angle (odds ratio=1.09, 95% confidence interval=1.06-1.11, p<0.001) and CAD severity. CONCLUSION It seems that CAD severity in patients who were non-diabetic and had stable angina pectoris is associated with the F-QRS-T angle.
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Affiliation(s)
- Halil Akın
- Department of Cardiology, Sinop Atatürk State Hospital; Sinop-Turkey
| | - Önder Bilge
- Department of Cardiology, Diyarbakır Gazi Yaşargil Training and Research Hospital; Diyarbakır-Turkey
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Xie Q, Huang J, Zhu K, Chen Q. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with coronary heart disease and type 2 diabetes mellitus: Cumulative meta-analysis. Clin Cardiol 2021; 44:899-906. [PMID: 34089266 PMCID: PMC8259162 DOI: 10.1002/clc.23613] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/07/2021] [Accepted: 04/16/2021] [Indexed: 01/19/2023] Open
Abstract
Previous meta‐analyses showed that coronary artery bypass grafting (CABG) has lower all‐cause mortality than percutaneous coronary intervention (PCI) for the management of coronary heart disease (CHD), but the long‐term outcomes were not analyzed thoroughly in patients with type 2 diabetes mellitus (T2DM). To perform a meta‐analysis of randomized controlled trials (RCTs) to explore the long‐term effectiveness between CABG and PCI in patients with T2DM and study the temporal trends using a cumulative meta‐analysis. PubMed, Embase, Cochrane library, and Clinical Trials Registry for eligible RCTs published up to September 2020. The outcomes were all‐cause death, cardiac death, myocardial infarction, repeat revascularization, and stroke. Nine RCTs and 4566 patients were included. CABG resulted in better outcomes than PCI in terms of all‐cause death (RR = 1.41, 95%CI: 1.22–1.63, p < 0.001), cardiac death (RR = 1.56, 95%CI: 1.25–1.95, p < 0.001), and repeat revascularization (RR = 2.68, 95%CI: 1.86–3.85, p < 0.001), but with difference regarding the occurrence of myocardial infarction (RR = 1.20, 95%CI: 0.78–1.85, p = 0.414), while PCI was associated with better outcomes in terms of stroke occurrence (RR = 0.51, 95%CI: 0.34–0.77, p = 0.001). The cumulative meta‐analysis for all‐cause death showed that the differences between CABG and PCI started to be significant at 3 years of follow‐up, while the difference became significant at 5 years for cardiac death. In patients with CHD and T2DM, CABG results in better outcomes than PCI in terms of all‐cause death, cardiac mortality, and repeat revascularization, while PCI had better outcomes in terms of stroke. The differences are mainly observed over the long‐term follow‐up.
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Affiliation(s)
- Qiuping Xie
- Department of Cardiology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Jianguo Huang
- Department of Cardiology, Liling Traditional Chinese Medicine Hospital, Zhuzhou, China
| | - Ke Zhu
- Department of Cardiology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Qing Chen
- Department of Cardiology, Zhuzhou Central Hospital, Zhuzhou, China
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Mølstad P, Nordrehaug JE, Steigen T, Wilsgaard T, Wiseth R, Bønaa KH. Analyses of Increased Mortality in New and Known Diabetes in Patients with Coronary Disease Enrolled in the NORSTENT Randomized Study. Cardiology 2021; 146:295-303. [PMID: 33691304 DOI: 10.1159/000513514] [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: 09/28/2020] [Accepted: 11/30/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND NORSTENT trial randomized 9,013 patients to percutaneous coronary intervention with drug-eluting stents (DES) or bare-metal stents (BMS) with a 5-year follow-up. Among the patients, 5,512 had measured either fasting glucose level or percent glycated hemoglobin (HbA1c) at the index procedure. That cohort constitutes the present study population analyzing mortality and evaluating treatment heterogeneity of randomized stent in diabetic versus nondiabetic subgroups. RESULTS The cohort consisted of 4,174 (75.7%) patients without diabetes, 716 (13.0%) with known diabetes, and 622 (11.3%) with no diabetes in history but elevated fasting glucose level >7.0 mmol/L or HbA1c >6.5% and therefore defined as new diabetes. Patients with known diabetes had a significantly increased all-cause (hazard ratio [HR] 1.99, 95% CI 1.51-2.62, p < 0.001), cardiac (subhazard ratio [SHR] 2.47, 95% CI 1.55-3.93, p < 0.001), and noncardiac (SHR 1.74, 95% CI 1.23-2.44, p = 0.002) mortality after adjustment for baseline variables. In the follow-up of 5 years, patients with new diabetes, however, had a marginally increased all-cause (HR 1.40, 95% CI 1.01-1.93, p = 0.043) and significantly increased noncardiac mortality (SHR 1.52, 95% CI 1.06-2.20, p = 0.025), but no increase in cardiac mortality (SHR 1.06, 95% CI 0.53-2.12, p = 0.86) after the same adjustment. The majority of the mortality was cardiac in the first 1-2 years after intervention; thereafter, noncardiac mortality dominated. However, the time period for when noncardiac mortality became the dominating cause varied considerably and significantly between the groups. There was no heterogeneity in mortality in response to randomized stent between diabetics and nondiabetics. CONCLUSION Known diabetes has increased cardiac and noncardiac mortality in contrast to new diabetes which is only associated with increased noncardiac mortality during the 5-year follow-up. Diabetic and nondiabetic patients have the same response to the treatment with BMS or DES.
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Affiliation(s)
- Per Mølstad
- Department of Cardiology, LHL Clinics Gardermoen, Jessheim, Norway,
| | | | - Terje Steigen
- University Hospital of North Norway and UiT The Arctic University of Norway, Tromsø, Norway
| | - Tom Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Rune Wiseth
- Clinic of Cardiology, St. Olavs University Hospital, and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kaare H Bønaa
- Clinic of Cardiology, St. Olavs University Hospital, and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Weinrauch L, D'Elia JA. Role of diabetes in residual risk among statin treated patients with prior cardiovascular events. J Diabetes Complications 2021; 35:107800. [PMID: 33386213 DOI: 10.1016/j.jdiacomp.2020.107800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 10/28/2020] [Indexed: 11/19/2022]
Affiliation(s)
| | - John A D'Elia
- Joslin Diabetes Center Harvard Medical School Boston, MA
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The advantage of surgical revascularization in diabetic patients with multivessel disease: More arterial conduits, more benefit. J Thorac Cardiovasc Surg 2021; 164:119-122. [PMID: 33785218 DOI: 10.1016/j.jtcvs.2021.01.140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/24/2020] [Accepted: 01/06/2021] [Indexed: 01/06/2023]
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Pliquett RU, Golle L, Wienke A, Girndt M. Prevalence of Incretin-Mimetic and Sodium-Glucose-Transporter-2-Inhibitor Therapy in German Hospitalized Type-2 Diabetics Following Myocardial Revascularization: An Observational Study. Diabetes Ther 2021; 12:247-259. [PMID: 33196958 PMCID: PMC7843777 DOI: 10.1007/s13300-020-00956-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 10/21/2020] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Real-world data indicate that sodium glucose transporter-2-inhibitor therapy and/or incretin mimetics are not widely prescribed in type-2 diabetics with atherosclerotic vascular disease. We hypothesized that incretin-mimetic therapy is associated with better overall survival and 1-year mortality in type-2 diabetics following myocardial revascularization. METHODS Hospitalized type-2 diabetics of the Departments of Cardiology and Cardiothoracic Surgery (University Hospital Halle) who needed myocardial revascularization (PCI or CABG) in 2016 were included in this observational study: group 1 (incretin-mimetic therapy), group 2 (insulin therapy without incretin mimetics) and group 3 (oral diabetes medication without incretins or insulin). They were asked to mail in a questionnaire on medical therapy and outcomes 1.9 years following discharge. In non-responders, vital status was obtained by local registration offices 2.4 years after discharge. RESULTS Two hundred four patients were recruited in this study. At discharge, only 4.4% of all type-2 diabetics were on incretin mimetic, 39.7% on insulin and 55.9% on oral diabetes medication. At the time of follow-up (response rate: 44.1%), there was no change in terms of prevalence of incretin-mimetic therapy (5.6% of responders). Prevalence of sodium glucose transporter-2-inhibitor therapy increased from 6.9% to 15.6% in responders. In-hospital mortality (group 1: 0%, group 2: 0%, group 3: 5.2%; p = 0.092), survival after discharge (group 1: 88.9%, group 2: 86.4%, group 3: 88.0%; p = 0.942) and number of rehospitalizations within 12 months after discharge (group 1: 1.0 per capita, group 2: 1.0, group 3: 1.1; p = 0.697) were similar among prespecified groups and between group 2 and 3. By 1.9-year follow-up, hypoglycemic events were more frequent in group 2 (1.5 ± 2.9) than in group 3 (0.02 ± 0.1; p = 0.0001). CONCLUSION The prevalence of incretin mimetics and sodium-glucose-transporter-2 inhibitors was low both during the index hospitalization and at a 1.9-year follow-up. When comparing group 2 and group 3 patients, survival and rehospitalizations were similar; hypoglycemic events occurred more often in insulin-treated diabetics than in the those without.
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Affiliation(s)
- Rainer U Pliquett
- Department of Internal Medicine II, University Hospital of the Martin Luther University Halle-Wittenberg, Halle, Germany.
| | - Linda Golle
- Department of Internal Medicine II, University Hospital of the Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biometry and Informatics, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Matthias Girndt
- Department of Internal Medicine II, University Hospital of the Martin Luther University Halle-Wittenberg, Halle, Germany
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Acampa W, Assante R, Zampella E, Petretta M, Cuocolo A. Myocardial perfusion imaging for diabetes: Key points from the evidence and clinical questions to be answered. J Nucl Cardiol 2020; 27:1569-1577. [PMID: 31410733 DOI: 10.1007/s12350-019-01846-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/30/2019] [Indexed: 11/29/2022]
Abstract
Diabetes represents a worldwide increasing problem and cardiovascular disease is the most common cause of death in diabetic patients. Pathophysiology that links diabetes to cardiovascular disease is a complex and multifactorial phenomenon evolving over time and involving both large blood vessels (macrovasculature) and small blood vessels (microvasculature). Myocardial perfusion imaging (MPI) imaging by both single-photon emission computer tomography and positron emission tomography with different specific tracers has become an indispensable tool for discriminating normal from diseased myocardial tissues and left ventricular function and monitoring myocardial blood flows, leading to the evaluation of almost overall physiologic consequences of the macro- and microvascular impairment involved in diabetic patients. This review will provide an overview of the role of MPI in the diagnosis and risk assessment of patients with diabetes and suspected or known CAD.
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Affiliation(s)
- Wanda Acampa
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy.
| | - Roberta Assante
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
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Yuan D, Zhang C, Jia S, Jiang L, Xu L, Zhang Y, Xu J, Xu B, Hui R, Gao R, Gao Z, Song L, Yuan J. Prediabetes and long-term outcomes in patients with three-vessel coronary artery disease: A large single-center cohort study. J Diabetes Investig 2020; 12:409-416. [PMID: 32686328 PMCID: PMC7926245 DOI: 10.1111/jdi.13361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 01/01/2023] Open
Abstract
Aims/Introduction Whether detection of prediabetes by routinely testing hemoglobin A1c and fasting plasma glucose in three‐vessel disease patients could identify individuals at high risk of future cardiovascular disease events remains unclear. This study evaluated the relationship between different glycemic status and clinical outcomes in this specific population. Materials and Methods This study included 8,891 Chinese patients with three‐vessel disease. Patients were categorized according to their glycemic status (normoglycemia [NG], n = 3,195; prediabetes, n = 1,978; diabetes mellitus, n = 3,718). Results The median follow‐up time was 7.5 years, during which 1,354 deaths and 2,340 major adverse cardiac and cerebrovascular events occurred. Compared with the NG group, patients in the prediabetes and diabetes mellitus groups had more comorbidities. After adjusting for confounders, the diabetes mellitus group had a higher risk of all‐cause death (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.20–1.53; P < 0.001), cardiac death (HR 1.35, 95% CI 1.14–1.61; P = 0.001) and major adverse cardiac and cerebrovascular events (HR 1.22, 95% CI 1.11–1.34; P < 0.001) compared with the NG group, whereas the prediabetes and NG groups had no significant difference. The diabetes mellitus group also had a higher risk of stroke compared with the NG group (HR 1.22, 95% CI 1.02–1.46; P = 0.031). Conclusions In the context of three‐vessel disease, prediabetes patients have comparable long‐term outcomes in terms of major adverse cardiac and cerebrovascular events, cardiac death and all‐cause death to those with NG. Routine screening of glycemic metabolism based on hemoglobin A1c and fasting plasma glucose might be valuable to identify individuals with diabetes mellitus who are at high risk of future cardiovascular disease events and individuals with prediabetes who are at high risk of progressing to diabetes mellitus.
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Affiliation(s)
- Deshan Yuan
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Ce Zhang
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Sida Jia
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lin Jiang
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lianjun Xu
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yin Zhang
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jingjing Xu
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Bo Xu
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Rutai Hui
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Runlin Gao
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Zhan Gao
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lei Song
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jinqing Yuan
- National Center for Cardiovascular Diseases, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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Jia S, Liu Y, Yuan J. Evidence in Guidelines for Treatment of Coronary Artery Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1177:37-73. [PMID: 32246443 DOI: 10.1007/978-981-15-2517-9_2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In this chapter, we focus on evidences in current guidelines for treatment of coronary artery disease (CAD). In Part 1, diet and lifestyle management is discussed, which plays an important role in CAD risk control, including forming healthy dietary pattern, maintaining proper body weight, physical exercise, smoking cessation, and so on. Part 2 elaborated on revascularization strategies and medical treatments in patients presenting with acute coronary syndrome (ACS), including specific AHA and ESC guidelines on ST elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS). Part 3 discussed chronic stable coronary artery disease (SCAD), the treatment objective of which is a combination of both symptomatic and prognostic improvement. Yet many of the recommendations for SCAD are expert-based rather than evidence-based. Initial medical treatment is safe and beneficial for most patients. While cumulating studies have focused on optimizing pharmacological therapy (referring to nitrates, beta-blockers, calcium channel blockers, antiplatelet agents, ACEI/ARB, statins, etc.), education, habitual modification, and social support matters a lot for reducing cardiac morbidity and mortality. Patients with moderate-to-severe symptoms and complex lesions should be considered for revascularization. But practical management of revascularization shall take individual characteristics, preference, and compliance into consideration as well.
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Affiliation(s)
- Sida Jia
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue Liu
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Mamet H, Petrie MC, Rocchiccioli P. Type 1 diabetes mellitus and coronary revascularization. Cardiovasc Endocrinol Metab 2019; 8:35-38. [PMID: 31646296 PMCID: PMC6739890 DOI: 10.1097/xce.0000000000000166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 01/21/2023]
Abstract
Over the last three decades, trials of coronary revascularization have taken into account whether populations did or did not have diabetes. What has not been considered is whether or not patients with diabetes in these studies have type 1 or type 2 diabetes. 'Diabetes' appears to be largely used as a synonym for type 2 diabetes. The number of patients with type 1 diabetes has not been reported in most trials. Many questions remain unanswered. Do patients with type 1 diabetes have the same response to various modes of revascularization as those with type 2 diabetes? We know type 2 diabetes affects coronary endothelial function and the coronary artery wall but to what extent does type 1 diabetes affect these? Any response to revascularization does not just depend on the coronary artery but also on the myocardium. How does type 1 diabetes affect the myocardium? To what extent do patients with type 1 diabetes have viable or ischaemic myocardium or scar? What does 'diabetic cardiomyopathy' refer to in the context of type 1 diabetes? This manuscript reviews the evidence for revascularization in type 1 diabetes. We conclude that there has been a near absence of investigation of the pros and cons of revascularization in this population. Investigations to establish both the nature and extent of coronary and myocardial disease in these populations are necessary. Clinical trials of the pros and cons of revascularization in type 1 diabetes are necessary; many will declare that these will be too challenging to perform.
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Affiliation(s)
- Helene Mamet
- Department of Cardiology, Golden Jubilee National Hospital
| | - Mark C. Petrie
- Department of Cardiology, Golden Jubilee National Hospital
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Farkouh ME, Domanski M, Dangas GD, Godoy LC, Mack MJ, Siami FS, Hamza TH, Shah B, Stefanini GG, Sidhu MS, Tanguay JF, Ramanathan K, Sharma SK, French J, Hueb W, Cohen DJ, Fuster V. Long-Term Survival Following Multivessel Revascularization in Patients With Diabetes: The FREEDOM Follow-On Study. J Am Coll Cardiol 2019; 73:629-638. [PMID: 30428398 PMCID: PMC6839829 DOI: 10.1016/j.jacc.2018.11.001] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/01/2018] [Accepted: 11/01/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial demonstrated that for patients with diabetes mellitus (DM) and multivessel coronary disease (MVD), coronary artery bypass grafting (CABG) is superior to percutaneous coronary intervention with drug-eluting stents (PCI-DES) in reducing the rate of major adverse cardiovascular and cerebrovascular events after a median follow-up of 3.8 years. It is not known, however, whether CABG confers a survival benefit after an extended follow-up period. OBJECTIVES The purpose of this study was to evaluate the long-term survival of DM patients with MVD undergoing coronary revascularization in the FREEDOM trial. METHODS The FREEDOM trial randomized 1,900 patients with DM and MVD to undergo either PCI with sirolimus-eluting or paclitaxel-eluting stents or CABG on a background of optimal medical therapy. After completion of the trial, enrolling centers and patients were invited to participate in the FREEDOM Follow-On study. Survival was evaluated using Kaplan-Meier analysis, and Cox proportional hazards models were used for subgroup and multivariate analyses. RESULTS A total of 25 centers (of 140 original centers) agreed to participate in the FREEDOM Follow-On study and contributed a total of 943 patients (49.6% of the original cohort) with a median follow-up of 7.5 years (range 0 to 13.2 years). Of the 1,900 patients, there were 314 deaths during the entire follow-up period (204 deaths in the original trial and 110 deaths in the FREEDOM Follow-On). The all-cause mortality rate was significantly higher in the PCI-DES group than in the CABG group (24.3% [159 deaths] vs. 18.3% [112 deaths]; hazard ratio: 1.36; 95% confidence interval: 1.07 to 1.74; p = 0.01). Of the 943 patients with extended follow-up, the all-cause mortality rate was 23.7% (99 deaths) in the PCI-DES group and 18.7% (72 deaths) in the CABG group (hazard ratio: 1.32; 95% confidence interval: 0.97 to 1.78; p = 0.076). CONCLUSIONS In patients with DM and MVD, coronary revascularization with CABG leads to lower all-cause mortality than with PCI-DES in long-term follow-up. (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450).
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Affiliation(s)
- Michael E Farkouh
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada.
| | | | - George D Dangas
- Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lucas C Godoy
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada; Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Flora S Siami
- New England Research Institutes, Watertown, Massachusetts
| | - Taye H Hamza
- New England Research Institutes, Watertown, Massachusetts
| | - Binita Shah
- VA New York Harbor Healthcare System, New York University School of Medicine, New York, New York
| | | | | | - Jean-François Tanguay
- Division of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | | | - Samin K Sharma
- Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John French
- Cardiology Department, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Whady Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - David J Cohen
- Saint-Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
| | - Valentin Fuster
- Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain.
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Zhuo X, Zhang C, Feng J, Ouyang S, Niu P, Dai Z. In-hospital, short-term and long-term adverse clinical outcomes observed in patients with type 2 diabetes mellitus vs non-diabetes mellitus following percutaneous coronary intervention: A meta-analysis including 139,774 patients. Medicine (Baltimore) 2019; 98:e14669. [PMID: 30813214 PMCID: PMC6408074 DOI: 10.1097/md.0000000000014669] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Several studies have shown that patients with type 2 diabetes mellitus (T2DM) have worse clinical outcomes in comparison to patients without diabetes mellitus (DM) following Percutaneous Coronary Intervention (PCI). However, the adverse clinical outcomes were not similarly reported in all the studies. Therefore, in order to standardize this issue, a meta-analysis including 139,774 patients was carried out to compare the in-hospital, short-term (<1 year) and long-term (≥1 year) adverse clinical outcomes in patients with and without T2DM following PCI. METHODS Electronic databases including MEDLINE, EMBASE, and the Cochrane Library were searched for Randomized Controlled Trials (RCTs) and observational studies. The adverse clinical outcomes which were analyzed included mortality, myocardial infarction (MI), major adverse cardiac events (MACEs), stroke, bleeding, target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis. Risk Ratios (RR) with 95% confidence intervals (CI) were used to express the pooled effect on discontinuous variables and the analysis was carried out by RevMan 5.3 software. RESULTS A total number of 139,774 participants were assessed. Results of this analysis showed that in-hospital mortality and MACEs were significantly higher in patients with T2DM (RR 2.57; 95% CI: 1.95-3.38; P = .00001) and (RR: 1.38; 95% CI: 1.10-1.73; P = .005) respectively. In addition, majority of the short and long-term adverse clinical outcomes were also significantly higher in the DM group as compared to the non-DM group. Stent thrombosis was significantly higher in the DM compared to the non-DM group during the short term follow-up period (RR 1.59; 95% CI: 1.16-2.18;P = .004). However, long-term stent thrombosis was similarly manifested. CONCLUSION According to this meta-analysis including a total number of 139,774 patients, following PCI, those patients with T2DM suffered more in-hospital, short as well as long-term adverse outcomes as reported by most of the Randomized Controlled Trials and Observational studies, compared to those patients without diabetes mellitus.
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Affiliation(s)
- Xiaojun Zhuo
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Hunan, Changsha
| | - Chuanzeng Zhang
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy, Nankai University, the city of Tianjin, Tianjin, PR China
| | - Juan Feng
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Hunan, Changsha
| | - Shenyu Ouyang
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Hunan, Changsha
| | - Pei Niu
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Hunan, Changsha
| | - Zhaohui Dai
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Hunan, Changsha
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Cuminetti G, Bonadei I, Vizzardi E, Sciatti E, Lorusso R. On-Pump Coronary Artery Bypass Graft: The State of the Art. Rev Recent Clin Trials 2019; 14:106-115. [PMID: 30836924 DOI: 10.2174/1574887114666190301142114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/21/2017] [Accepted: 12/05/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) remains the standard of care for patients with coronary artery disease (CAD). Debate exists concerning several factors, which include percutaneous coronary intervention (PCI) vs. CABG, single vs. bilateral mammary artery grafts, radial artery vs. saphenous vein grafts, right internal mammary artery vs. radial artery grafts, endoscopic vs. open vein-graft harvesting, and on-pump vs. off- pump surgery. Moreover, challenging is the management of diabetic patients with CAD undergoing CABG. This review reports current indications, practice patterns, and outcomes of CABG. METHODS Randomized controlled trials comparing CABG to other therapeutical strategies for CAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. RESULTS Large multicenter randomized and observational studies (SYNTAX, BEST, PRECOMBAT, ASCERT) have reported excellent outcomes in CABG patients, with always fewer rates of operative mortality and major morbidity, than PCI. The 10-year follow-up of ARTS II trial showed no difference between single and bilateral mammary artery. BARI 2D, MASS II, CARDia, FREEDOM trials showed that CABG is the best choice for diabetic patients. CONCLUSION CABG still represents one of the most widespread major surgeries, with well-known benefits on symptoms and prognosis in patients with CAD. However, further studies and follow-up data are needed to validate these evidences.
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Affiliation(s)
- Giovanni Cuminetti
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Ivano Bonadei
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Enrico Vizzardi
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Edoardo Sciatti
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
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Esper RB, Farkouh ME, Ribeiro EE, Hueb W, Domanski M, Hamza TH, Siami FS, Godoy LC, Mathew V, French J, Fuster V. SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization in the FREEDOM Trial. J Am Coll Cardiol 2018; 72:2826-2837. [DOI: 10.1016/j.jacc.2018.09.046] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 01/25/2023]
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Mosleh W, Sharma A, Sidhu MS, Page B, Sharma UC, Farkouh ME. The Role of SGLT-2 Inhibitors as Part of Optimal Medical Therapy in Improving Cardiovascular Outcomes in Patients with Diabetes and Coronary Artery Disease. Cardiovasc Drugs Ther 2018; 31:311-318. [PMID: 28536852 DOI: 10.1007/s10557-017-6729-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The optimal treatment approach to patients with coronary artery disease (CAD), including those with type 2 diabetes mellitus (T2DM), has been extensively evaluated. Several trials of stable ischemic heart disease including patients with T2DM have demonstrated that medical management is comparable to revascularization in terms of mortality and rates of major adverse cardiovascular events (MACE). There has been a growing appreciation for optimal medical therapy's (OMT) role in improving clinical outcomes. It is vital to target T2DM patients to prevent or delay MACE events through advanced OMT, ultimately delaying if not avoiding the need for revascularization. There has been significant evolution in the development of pharmacologic management of T2DM patients. Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a new pharmacologic therapy with tremendous potential to alter clinical practice and influence practice guidelines. SGLT2-inhibitors have great potential in reducing MACE in patients with T2DM and CAD. Empagliflozin should be considered as a part of OMT among these patients. If results similar to the EMPA-REG OUTCOMES trial are replicated in other trials, the use of these pharmacologic agents as a part of OMT may narrow the gap between revascularization and OMT alone in patients with T2DM and multi-vessel disease. Future studies on the role of SLGT-2 inhibitors with regard to heart failure outcomes are needed to elucidate the mechanisms and clinical effects in this vulnerable population.
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Affiliation(s)
- Wassim Mosleh
- University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Abhinav Sharma
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Mandeep S Sidhu
- Department of Medicine, Albany Medical College, Albany Medical Center, Albany, NY, USA
| | - Brian Page
- University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Umesh C Sharma
- University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, University Health Network, 585 University Avenue, 4N474, Toronto, ON, M5G 2N2, Canada. .,The Heart and Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, University of Toronto, Toronto, ON, Canada.
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Mølstad P, Rødevand O. Survival in Type 1 and Type 2 Diabetes in a Population Referred for Invasive Evaluation of Coronary Disease. Cardiology 2017; 139:43-52. [PMID: 29224016 DOI: 10.1159/000484235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 09/26/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate long-term and time trends of survival in patients with a clinical diagnosis of type 1 and type 2 diabetes compared to patients without diabetes in a population referred for invasive treatment of coronary disease. METHODS Patients examined for heart disease at the Feiring LHL Clinics from March 1999 until December 2014 were followed for survival until 20 September, 2015. This yielded 43,872 patients with a known survival status including 1,326 (3.0%) patients with type 1 diabetes and 4,564 (10.9%) with type 2 diabetes. RESULTS Cox regression revealed a hazard ratio (HR) in type 1 and type 2 diabetes, respectively, of 1.78 (95% confidence interval [CI] 1.60-1.99) and 1.29 (95% CI 1.21-1.37). Comparing survival in the treatment periods before and after 2007, patients without diabetes and with type 2 diabetes had a reduced HR of 0.78 (95% CI 0.72-0.84) and 0.76 (95% CI 0.63-0.91), respectively, but there was no reduction in type 1 diabetes (HR 1.03; 95% CI 0.74-1.42). CONCLUSIONS Type 1 and type 2 diabetes have excess long-term mortality. In the nondiabetic and type 2 diabetic patients, a reduction in mortality has been noted in recent years, but has not been observed in type 1 diabetic patients.
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Affiliation(s)
- Per Mølstad
- Department of Cardiology, Feiring LHL Clinics, Feiring, Norway
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Badour SA, Dimitrova KR, Kanei Y, Tranbaugh RF, Hajjar MM, Kabour A, Schwann TA, Alam S, Badr K, Habib RH. First and second generation DESs reduce diabetes adverse effect on mortality and re-intervention in multivessel coronary disease: 9-Year analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:265-273. [PMID: 28314676 DOI: 10.1016/j.carrev.2017.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/23/2017] [Accepted: 01/27/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND/PURPOSE Diabetes portends an increased risk of adverse early and late outcomes in patients undergoing PCI. In this study, we aimed to investigate if the adverse effect of diabetes mellitus (DM) on early and late PCI outcomes is reduced with drug-eluting (DES) compared to bare-metal (BMS) stents. METHODS/MATERIALS We reviewed the Mount Sinai Beth Israel Hospital first PCI experience for multivessel coronary artery disease (CAD, 1998-2009). Patients were excluded if they had single-vessel CAD, emergency, no stent, prior bypass graft or myocardial infarction <24h. Diabetes-effect was derived from 9-year all-cause mortality and re-intervention risk-adjusted hazard ratios [AHR (95% confidence intervals)] for DES (N=2679; 48% three-vessel; 39% DM) and BMS (N=2651; 40% three-vessel; 33% DM) and then stratified based on stent (DES/BMS) and vessel disease (two/three). RESULTS Diabetes-effect on mortality was lower for DES (AHRDM/NoDM=1.41 [1.14-1.74]) versus BMS (AHRDM/NoDM=1.71 [1.50-2.01]), but this was predominantly driven by two-vessel patients. This diabetes effect was similar for first (DES1: AHRDM/NoDM=1.43 [1.14-1.79]) and second (DES2: AHRDM/NoDM=1.53 [0.77-3.07]) generation DES. Re-intervention comparisons were similarly increased by diabetes in all sub-cohorts. CONCLUSIONS Our analysis of a large real-world PCI series indicates that diabetes is associated with worse 9-year mortality irrespective of stent type, albeit this is mitigated to varying degrees with DES, particularly in DES2 and in case of 2-vessel disease. A complementary stent-effect analysis confirmed DES-to-BMS and DES2-to-DES1 superiority in both diabetics and non-diabetics.
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Affiliation(s)
- Sanaa A Badour
- Department of Internal Medicine, Vascular Medicine Program and Outcomes Research Unit, American University of Beirut, Lebanon
| | - Kamellia R Dimitrova
- Divisions of Cardiology, Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - Yumiko Kanei
- Cardiothoracic Surgery, Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - Robert F Tranbaugh
- Divisions of Cardiology, Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - Mark M Hajjar
- Department of Internal Medicine, Vascular Medicine Program and Outcomes Research Unit, American University of Beirut, Lebanon
| | - Ameer Kabour
- Division of Cardiology, Mercy Saint Vincent Medical Center, Toledo, OH, USA
| | - Thomas A Schwann
- Department of Surgery, University of Toledo College of Medicine, Toledo, OH, USA
| | - Samir Alam
- Department of Internal Medicine, Vascular Medicine Program and Outcomes Research Unit, American University of Beirut, Lebanon
| | - Kamal Badr
- Department of Internal Medicine, Vascular Medicine Program and Outcomes Research Unit, American University of Beirut, Lebanon
| | - Robert H Habib
- Department of Internal Medicine, Vascular Medicine Program and Outcomes Research Unit, American University of Beirut, Lebanon.
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Szychta W, Majstrak F, Opolski G, Filipiak KJ. Blood glucose concentration for predicting poor outcomes in patients with and without impaired glucose metabolism undergoing off-pump coronary artery bypass surgery - long-term observational study. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2016; 12:238-46. [PMID: 27625687 PMCID: PMC5011540 DOI: 10.5114/aic.2016.61646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 12/15/2015] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Strict glucose control is an everyday practice in the perioperative period. Elevated glucose level has a deleterious impact on clinical results, but a therapeutic target has not been stated yet. AIM To determine a glucose concentration range affecting long-term outcomes after coronary artery bypass surgery (CABG). MATERIAL AND METHODS This study is a retrospective evaluation of consecutive patients treated in a university hospital in Poland from 2004 to 2008. Patients were divided into 2 groups: an impaired glucose metabolism group (IGM) if they had 1) known DM or 2) perioperative hyperglycaemia defined as ≥ 200 mg/dl; and a non-IGM group. The end point (EP) was all-cause mortality. RESULTS One thousand two hundred and eleven patients were covered by the analysis. The observation time was from 01.01.2004 until 01.08.2012. Patients who had maximal glucose concentrations < 242 mg/dl had the lowest mortality risk (EP in 21.1%); a higher risk was noted in the group with glucose concentrations 242-324 mg/dl (EP in 30.8%); and a very high risk was found for the group where glucose concentration was > 324 mg/dl (EP in 44.2%) (p = 0.041). Patients with IGM had a shorter survival at the end of the study (p < 0.001). The longest survival was observed in patients whose maximal glucose level was ≤ 242 mg/dl (p < 0.001) and the minimal glucose concentration was in the range 61-110 mg/dl (p < 0.001). CONCLUSIONS Tight glucose concentration control should be performed irrespective of a diabetes diagnosis and proper treatment introduced when necessary. Maximal glucose concentration should be kept < 242 mg/dl, while the minimum should be in the range 60-110 mg/dl.
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Affiliation(s)
- Wojciech Szychta
- 1 Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Franciszek Majstrak
- Department of Cardiac Surgery, 1 Chair of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Opolski
- 1 Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
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Lima EG, Hueb W, Gersh BJ, Rezende PC, Garzillo CL, Favarato D, Hueb AC, Rahmi Garcia RM, Franchini Ramires JA, Filho RK. Impact of Chronic Kidney Disease on Long-Term Outcomes in Type 2 Diabetic Patients With Coronary Artery Disease on Surgical, Angioplasty, or Medical Treatment. Ann Thorac Surg 2016; 101:1735-44. [DOI: 10.1016/j.athoracsur.2015.10.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 10/01/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
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Coronary artery bypass surgery compared with percutaneous coronary interventions in patients with insulin-treated type 2 diabetes mellitus: a systematic review and meta-analysis of 6 randomized controlled trials. Cardiovasc Diabetol 2016; 15:2. [PMID: 26739589 PMCID: PMC4702412 DOI: 10.1186/s12933-015-0323-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 12/28/2015] [Indexed: 12/11/2022] Open
Abstract
Background Data regarding the long-term clinical outcomes in patients with insulin-treated type 2 diabetes mellitus (ITDM) revascularized by either coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) are still controversial. We sought to compare the long-term (≥1 year) adverse clinical outcomes in patients with ITDM who underwent revascularization by either CABG or PCI. Methods Randomized Controlled Trials (RCTs) comparing the long-term clinical outcomes in patients with ITDM and non-ITDM revascularized by either CABG or PCI were searched from electronic databases. Data for patients with ITDM were carefully retrieved. 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 Six RCTs involving 10 studies, with a total of 1297 patients with ITDM were analyzed (639 patients from the CABG group and 658 patients from the PCI group). CABG was associated with a significantly lower mortality rate compared to PCI with OR: 0.59, 95 % CI 0.42–0.85; P = 0.004. Major adverse cardiovascular and cerebrovascular events as well as repeated revascularization were also significantly lower in the CABG group with OR: 0.51, 95 % CI 0.27–0.99; P = 0.03 and OR 0.34, 95 % CI 0.24–0.49; P < 0.00001 respectively. However, compared to PCI, the rate of stroke was higher in the CABG group with OR: 1.41, 95 % CI 0.64–3.09; P = 0.40, but this result was not statistically significant. Conclusion CABG was associated with significantly lower long-term adverse clinical outcomes compared to PCI in patients with ITDM. However, due to an insignificantly higher rate of stroke in the CABG group, further researches with a larger number of randomized patients are required to completely solve this issue.
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Rezende PC, Rahmi RM, Hueb W. The Influence of Diabetes Mellitus in Myocardial Ischemic Preconditioning. J Diabetes Res 2016; 2016:8963403. [PMID: 27656659 PMCID: PMC5021496 DOI: 10.1155/2016/8963403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/14/2016] [Indexed: 11/24/2022] Open
Abstract
Ischemic preconditioning (IP) is a powerful mechanism of protection discovered in the heart in which ischemia paradoxically protects the myocardium against other ischemic insults. Many factors such as diseases and medications may influence IP expression. Although diabetes poses higher cardiovascular risk, the physiopathology underlying this condition is uncertain. Moreover, although diabetes is believed to alter intracellular pathways related to myocardial protective mechanisms, it is still controversial whether diabetes may interfere with ischemic preconditioning and whether this might influence clinical outcomes. This review article looks at published reports with animal models and humans that tried to evaluate the possible influence of diabetes in myocardial ischemic preconditioning.
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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute of the University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Rosa Maria Rahmi
- Department of Atherosclerosis, Heart Institute of the University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Whady Hueb
- Department of Atherosclerosis, Heart Institute of the University of São Paulo Medical School, São Paulo, SP, Brazil
- *Whady Hueb:
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Herbison P, Wong CK. Has the difference in mortality between percutaneous coronary intervention and coronary artery bypass grafting in people with heart disease and diabetes changed over the years? A systematic review and meta-regression. BMJ Open 2015; 5:e010055. [PMID: 26719324 PMCID: PMC4710812 DOI: 10.1136/bmjopen-2015-010055] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To examine the difference in outcome between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), to see if it has changed over the years in diabetics deemed eligible for both treatments; and to contrast the long-term mortality findings with those in non-diabetics. DESIGN Meta-analyses using data from randomised controlled trials found by searches on MEDLINE, EMBASE and the Cochrane Controlled Trials Register, from their inception until March 2015. SETTING Studies had to be randomised controlled trials comparing PCI with CABG. PARTICIPANTS Those taking part in the studies had to have multivessel cardiac or left main artery cardiac disease and be deemed eligible for both treatments. INTERVENTIONS PCI or CABG. PRIMARY AND SECONDARY OUTCOMES The primary outcome was all cause mortality. Secondary outcomes were a composite of mortality, stroke and myocardial infarction; cardiovascular death; and MACCE (Major Adverse Cardiac or Cerebrovascular Event). The longest follow-up was used in the analysis. RESULTS Among 14 studies (4868 diabetics) reported over three decades, meta-regression shows no relationship between the year of publication and the difference in long term all cause mortality between PCI and CABG. CABG has maintained an approximately 30% mortality advantage compared to PCI. The other outcomes used showed the same lack of change over the years. These findings held true among insulin-requiring and non-insulin-requiring diabetics. However, among non-diabetics included in the 14 studies, there was no difference in mortality outcome between PCI and CABG. CONCLUSIONS The difference in outcome between PCI and CABG in diabetics has not narrowed from the beginning-with balloon angioplasty to current PCI-with the second generation of drug eluting stents. In contrast to the non-diabetics, there is a persistent 30% benefit in all cause mortality favouring CABG in diabetics, and this should be a major factor in treatment recommendation.
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Affiliation(s)
- Peter Herbison
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Cheuk-Kit Wong
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Department of Medicine and Therapeutics, Chinese University of Hong Kong Shatin, New Territories, Hong Kong
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Bundhun PK, Wu ZJ, Chen MH. Impact of Modifiable Cardiovascular Risk Factors on Mortality After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of 100 Studies. Medicine (Baltimore) 2015; 94:e2313. [PMID: 26683970 PMCID: PMC5058942 DOI: 10.1097/md.0000000000002313] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/05/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
Modifiable cardiovascular risk factors such as obesity, hypertension, dyslipidemia, smoking, diabetes mellitus, and metabolic syndrome can easily give rise to coronary heart disease (CHD). However, due to the existence of the so-called "obesity paradox" and "smoking paradox," the impact of these modifiable cardiovascular risk factors on mortality after percutaneous coronary intervention (PCI) is still not clear. Therefore, in order to solve this issue, we aim to compare mortality between patients with low and high modifiable cardiovascular risk factors after PCI. Medline and EMBASE were searched for studies related to these modifiable cardiovascular risk factors. Reported outcome was all-cause mortality after PCI. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated, and the pooled analyses were performed with RevMan 5.3 software. A total of 100 studies consisting of 884,190 patients (330,068 and 514,122 with high and low cardiovascular risk factors respectively) have been included in this meta-analysis. Diabetes mellitus was associated with a significantly higher short and long-term mortality with RR 2.11; 95% CI: (1.91-2.33) and 1.85; 95% CI: (1.66-2.06), respectively, after PCI. A significantly higher long-term mortality in the hypertensive and metabolic syndrome patients with RR 1.45; 95% CI: (1.24-1.69) and RR 1.29; 95% CI: (1.11-1.51), respectively, has also been observed. However, an unexpectedly, significantly lower mortality risk was observed among the smokers and obese patients. Certain modifiable cardiovascular risk subgroups had a significantly higher impact on mortality after PCI. However, mortality among the obese patients and the smokers showed an unexpected paradox after coronary intervention.
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Affiliation(s)
- Pravesh Kumar Bundhun
- From the Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P.R. China
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Luthra S, Leiva-Juárez MM, Taggart DP. Systematic Review of Therapies for Stable Coronary Artery Disease in Diabetic Patients. Ann Thorac Surg 2015; 100:2383-97. [PMID: 26530540 DOI: 10.1016/j.athoracsur.2015.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 06/29/2015] [Accepted: 07/09/2015] [Indexed: 10/22/2022]
Abstract
Diabetes mellitus is a significant risk modifier for stable coronary artery disease, causing patients to have more extensive and diffuse lesions. Opposing treatment strategies remain a matter of debate. A multiple database search was conducted and outcomes, lesion, and patient characteristics were compared. Overall mortality, cardiac death, major adverse cardiovascular and cerebrovascular events, and need for revascularization were higher with percutaneous coronary intervention than with coronary artery bypass graft surgery. Multivessel disease and high Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) scores were associated with better outcomes for coronary artery bypass graft surgery.
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Affiliation(s)
- Suvitesh Luthra
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts.
| | - Miguel M Leiva-Juárez
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts
| | - David P Taggart
- Oxford Heart Center, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS guidelines on myocardial revascularization. EUROINTERVENTION 2015; 10:1024-94. [PMID: 25187201 DOI: 10.4244/eijy14m09_01] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Stephan Windecker
- Cardiology, Bern University Hospital, Freiburgstrasse 4, CH-3010 Bern, Switzerland
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Rezende PC, Rahmi RM, Uchida AH, da Costa LMA, Scudeler TL, Garzillo CL, Lima EG, Segre CAW, Girardi P, Takiuti M, Silva MF, Hueb W, Ramires JAF, Kalil Filho R. Type 2 diabetes mellitus and myocardial ischemic preconditioning in symptomatic coronary artery disease patients. Cardiovasc Diabetol 2015; 14:66. [PMID: 26025451 PMCID: PMC4451743 DOI: 10.1186/s12933-015-0228-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/21/2015] [Indexed: 01/10/2023] Open
Abstract
Background The influence of diabetes mellitus on myocardial ischemic preconditioning is not clearly defined. Experimental studies are conflicting and human studies are scarce and inconclusive. Objectives Identify whether diabetes mellitus intervenes on ischemic preconditioning in symptomatic coronary artery disease patients. Methods Symptomatic multivessel coronary artery disease patients with preserved systolic ventricular function and a positive exercise test underwent two sequential exercise tests to demonstrate ischemic preconditioning. Ischemic parameters were compared among patients with and without type 2 diabetes mellitus. Ischemic preconditioning was considered present when the time to 1.0 mm ST deviation and rate pressure-product were greater in the second of 2 exercise tests. Sequential exercise tests were analyzed by 2 independent cardiologists. Results Of the 2,140 consecutive coronary artery disease patients screened, 361 met inclusion criteria, and 174 patients (64.2 ± 7.6 years) completed the study protocol. Of these, 86 had the diagnosis of type 2 diabetes. Among diabetic patients, 62 (72 %) manifested an improvement in ischemic parameters consistent with ischemic preconditioning, whereas among nondiabetic patients, 60 (68 %) manifested ischemic preconditioning (p = 0.62). The analysis of patients who demonstrated ischemic preconditioning showed similar improvement in the time to 1.0 mm ST deviation between diabetic and nondiabetic groups (79.4 ± 47.6 vs 65.5 ± 36.4 s, respectively, p = 0.12). Regarding rate pressure-product, the improvement was greater in diabetic compared to nondiabetic patients (3011 ± 2430 vs 2081 ± 2139 bpm x mmHg, respectively, p = 0.01). Conclusions In this study, diabetes mellitus was not associated with impairment in ischemic preconditioning in symptomatic coronary artery disease patients. Furthermore, diabetic patients experienced an improvement in this significant mechanism of myocardial protection.
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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Rosa Maria Rahmi
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Augusto Hiroshi Uchida
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Leandro Menezes Alves da Costa
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Thiago Luis Scudeler
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Cibele Larrosa Garzillo
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Eduardo Gomes Lima
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Carlos Alexandre Wainrober Segre
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Priscyla Girardi
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Myrthes Takiuti
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Marcela Francisca Silva
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Jose Antonio Franchini Ramires
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Roberto Kalil Filho
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
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Toklu B, Bangalore S. Comparison of coronary artery bypass graft surgery and percutaneous coronary intervention in patients with diabetes. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:377. [PMID: 25800127 DOI: 10.1007/s11936-015-0377-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OPINION STATEMENT The optimal revascularization strategy in patients with diabetes is controversial. The Bypass Angioplasty Revascularization Investigation (BARI) trial, done more than a decade ago, suggested a mortality benefit of coronary artery bypass graft surgery (CABG) when compared with percutaneous coronary intervention (PCI) (with plain old balloon angioplasty) in the subgroup of patients with diabetes. In addition, several observational studies and meta-analyses similarly suggest a benefit of CABG over PCI in patients with diabetes. However, most of these studies compared CABG with PCI using balloon angioplasty, bare metal stents, or first-generation drug-eluting stents. In this review, we critically examine the data for optimal revascularization strategy in patients with diabetes and ask the question whether the currently available data from randomized trials that used outdated stents are applicable to current day practice.
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Affiliation(s)
- Bora Toklu
- New York University School of Medicine, New York, NY, 10016, USA
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Deb S, Fremes SE. To bypass or stent? The changing rules of an advancing game. J Thorac Cardiovasc Surg 2015; 149:679-81. [DOI: 10.1016/j.jtcvs.2014.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
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Rezende PC, Scudeler TL, da Costa LMA, Hueb W. Conservative strategy for treatment of stable coronary artery disease. World J Clin Cases 2015; 3:163-170. [PMID: 25685763 PMCID: PMC4317610 DOI: 10.12998/wjcc.v3.i2.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/25/2014] [Indexed: 02/05/2023] Open
Abstract
Patients with coronary artery disease vary widely in terms of prognosis, which is mainly dependent on ventricular function. In relation to the major outcomes of death and myocardial infarction, it is not clear in the literature if an invasive strategy of myocardial revascularization is superior to a conservative strategy of optimized medical therapy. Moreover, with the exception of patients with left main coronary disease, this similarity in prognosis also occurs in different subgroups of patients.
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Giallauria F, Fattirolli F, Tramarin R, Ambrosetti M, Griffo R, Riccio C, De Feo S, Piepoli MF, Vigorito C. Clinical characteristics and course of patients with diabetes entering cardiac rehabilitation. Diabetes Res Clin Pract 2015; 107:267-72. [PMID: 25497465 DOI: 10.1016/j.diabres.2014.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/20/2014] [Accepted: 11/24/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Using data from the Italian SurveY on carDiac rEhabilitation (ISYDE-2008), this study provides insight into the level of implementation of Cardiac Rehabilitation (CR) in patients with diabetes. METHODS Data from 165 CR units were collected online from January 28th to February 10th, 2008. RESULTS The study cohort consisted of 2281 patients (66.9 ± 12 yrs); 475 (69.7 ± 10 yrs, 74% male) patients with diabetes and 1806 (66.2 ± 12 yrs, 72% male) non-diabetic patients. Compared to non-diabetic patients, patients with diabetes were older and showed more comorbidity [myocardial infarction (32% vs. 19%, p < 0.0001), peripheral artery disease (10% vs. 5%, p < 0.0001), chronic obstructive pulmonary disease (20% vs. 11%, p < 0.0001), chronic kidney disease (20% vs. 6%, p < 0.0001), and cognitive impairment (5% vs. 2%, p = 0.0009), respectively], and complications during CR [re-infarction (3% vs. 1%, p = 0.04), acute renal failure (9% vs. 4%, p < 0.0001), sternal revision (3% vs. 1%, p = 0.01), inotropic support/mechanical assistance (7% vs. 4%, p = 0.01), respectively]; a more complex clinical course and interventions with less functional evaluation and a different pattern of drug therapy at hospital discharge. Notably, in 51 (3%) and in 104 (6%) of the non-diabetic cohort, insulin and hypoglycemic agents were prescribed, respectively, at hospital discharge from CR suggesting a careful evaluation of the glycemic metabolism during CR program, independent of the diagnosis at the admission. Mortality was similar among diabetic compared to non-diabetic patients (1% vs. 0.5%, p = 0.23). CONCLUSIONS This survey provided a detailed overview of the clinical characteristics, complexity and more severe clinical course of diabetic patients admitted to CR.
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Affiliation(s)
- Francesco Giallauria
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, University of Naples "Federico II", Naples, Italy.
| | - Francesco Fattirolli
- Department of Critical Care Medicine and Surgery, Cardiac Rehabilitation Unit, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Roberto Tramarin
- Cardiac Rehabilitation Unit, IRCCS Policlinico San Donato, Italy
| | - Marco Ambrosetti
- Cardiovascular Rehabilitation Unit, Le Terrazze Clinic, Cunardo, Italy
| | - Raffaele Griffo
- Cardiac Rehabilitation Unit, Department of Cardiology, La Colletta Hospital, Arenzano, Italy
| | - Carmine Riccio
- Cardiac Rehabilitation, Azienda Ospedaliera S. Anna e S. Sebastiano di Caserta, Italy
| | - Stefania De Feo
- Cardiology Unit, Dr Pederzoli Clinic, Peschiera del Garda, Italy
| | | | - Carlo Vigorito
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, University of Naples "Federico II", Naples, Italy
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Verdoia M, Barbieri L, Schaffer A, Cassetti E, Di Giovine G, Nardin M, Bellomo G, Marino P, De Luca G. Effect of diabetes mellitus on periprocedural myocardial infarction in patients undergoing coronary stent implantation. Diabetes Metab Res Rev 2015; 31:85-92. [PMID: 24898423 DOI: 10.1002/dmrr.2567] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 05/07/2014] [Accepted: 05/31/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND Diabetic patients undergoing percutaneous coronary interventions are still regarded as a very high risk category because of an increased platelet reactivity and risk of complications, especially in patients with inadequate glycaemic control. However, although its prognostic effect on long-term outcome is well-defined, still unclear is the effect of diabetes on the risk of periprocedural myocardial infarction in patients undergoing percutaneous coronary interventions, which was therefore the aim of our study. METHODS Myonecrosis biomarkers were dosed at intervals from 6 to 48 h after nonemergent percutaneous coronary interventions. Periprocedural myocardial infarction was defined as creatine kinase-MB increase by three times the upper limit normal or by 50% of an elevated baseline value, whereas periprocedural myonecrosis as troponin I increase by three times the upper limit normal or 50% of baseline. RESULTS Of 1311 patients, diabetes mellitus was found in 458 patients (34.9%) and associated with age (p = 0.03), hypertension (p < 0.001), renal failure (p = 0.01), previous MI (p = 0.03), previous coronary revascularization (p < 0.001), higher fasting glycaemia and lower haemoglobin (p < 0.001), more severe coronary disease (p < 0.001), multivessel percutaneous coronary interventions (p = 0.03), coronary calcification (p = 0.003) and in-stent restenosis (p < 0.001) but lower presence of thrombus (p = 0.03). Diabetic patients were receiving significantly more frequent specific pharmacological treatment at admission. Diabetic status did not influence the risk of periprocedural myocardial infarction or periprocedural myonecrosis [adjusted OR(95%CI) = 0.90(0.64-1.27), p = 0.57 and adjusted OR(95%CI) = 0.92(0.70-1.21), p = 0.55]. Amongst diabetic patients, we did not observe any effect of chronic glycaemic control on periprocedural myocardial infarction. CONCLUSIONS Diabetic status, independent of chronic glycaemic control, is not associated with increased risk of periprocedural myocardial infarction and myonecrosis in patients undergoing percutaneous coronary interventions.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria 'Maggiore della Carità', Eastern Piedmont University, Novara, Italy
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Smit Y, Vlayen J, Koppenaal H, Eefting F, Kappetein AP, Mariani MA. Percutaneous coronary invervention versus coronary artery bypass grafting: a meta-analysis. J Thorac Cardiovasc Surg 2014; 149:831-8.e1-13. [PMID: 25467373 DOI: 10.1016/j.jtcvs.2014.10.112] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 10/17/2014] [Accepted: 10/25/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with coronary artery disease. METHODS MEDLINE, Embase, and Cochrane Central were searched, and randomized controlled trials were included. Outcomes were assessed at maximum available follow-up. RESULTS This meta-analysis includes 31 trials with 15,004 patients. As regards death, more patients died after PCI compared with CABG across all types of patients (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.3; P = .05) as well as in patients with multivessel disease (OR, 1.2; 95% CI, 1.0-1.4; P = .02) or diabetes (OR, 1.6; 95% CI, 1.2-2.1; P < .01). Myocardial infarction occurred as frequently after PCI (OR, 1.2; 95% CI, 0.9-1.5; P = .28). Repeat revascularization was more common after PCI (OR, 4.5; 95% CI, 3.5-5.8; P < .01), with a progressive decline in ORs from the pre-stent era (OR, 7.0; 95% CI, 5.1-9.7; P < .01), to the bare metal stent era (OR, 4.5; 95% CI, 3.6-5.5; P < .01), and to the drug-eluting stent era (OR, 2.5; 95% CI, 1.8-3.4; P < .01). Stroke was more common after CABG (OR, 0.7; 95% CI, 0.5-0.9; P = .01). CONCLUSIONS Compared with PCI, CABG had a lower risk of death in multivessel disease or diabetes patients eligible for either intervention, a lower risk of repeat revascularization, but a higher risk of stroke.
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Affiliation(s)
- Yolba Smit
- Independent Researcher, Leuth, The Netherlands
| | | | | | - Frank Eefting
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus Medisch Centrum, Rotterdam, The Netherlands
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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Nicolini F, Agostinelli A, Vezzani A, Benassi F, Gherli T. CABG versus PCI in the treatment of diabetic patients affected by coronary artery disease. Int Heart J 2014; 55:469-73. [PMID: 25297505 DOI: 10.1536/ihj.14-061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Surgical coronary revascularization and percutaneous coronary intervention were demonstrated to be effective treatments for coronary artery disease. However, the optimal revascularization strategy remains unclear in certain patient subsets. The recently published Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial is a randomized study evaluating the use of CABG versus PCI in diabetic patients with multivessel coronary disease. The purpose of this study was to review the available literature based on randomized trials and observational studies in order to allow clinicians to make evidence-based decisions when treating diabetic patients with multivessel coronary disease. The current evidence suggests that CABG should remain the standard of care for this patient population.
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Affiliation(s)
- Francesco Nicolini
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541-619. [PMID: 25173339 DOI: 10.1093/eurheartj/ehu278] [Citation(s) in RCA: 3326] [Impact Index Per Article: 332.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Rezende PC, Garcia RMR, Uchida AH, Costa LMA, Scudeler TL, Melo RMV, Oikawa FTC, Garzillo CL, Lima EG, Segre CAW, Favarato D, Girardi P, Takiuti M, Strunz CC, Hueb W, Ramires JAF, Filho RK. Hypotheses, rationale, design, and methods for evaluation of ischemic preconditioning assessed by sequential exercise tests in diabetic and non-diabetic patients with stable coronary artery disease--a prospective study. BMC Cardiovasc Disord 2013; 13:117. [PMID: 24330253 PMCID: PMC4029531 DOI: 10.1186/1471-2261-13-117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/03/2013] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Ischemic preconditioning is a powerful mechanism of myocardial protection and in humans it can be evaluated by sequential exercise tests. Coronary Artery Disease in the presence of diabetes mellitus may be associated with worse outcomes. In addition, some studies have shown that diabetes interferes negatively with the development of ischemic preconditioning. However, it is still unknown whether diabetes may influence the expression of ischemic preconditioning in patients with stable multivessel coronary artery disease. METHODS/DESIGN This study will include 140 diabetic and non-diabetic patients with chronic, stable coronary artery disease and preserved left ventricular systolic function. The patients will be submitted to two sequential exercise tests with 30-minutes interval between them. Ischemic parameters will be compared between diabetic and non-diabetic patients. Ischemic preconditioning will be considered present when time to 1.0 mm ST-segment deviation is greater in the second of two sequential exercise tests. Exercise tests will be analyzed by two independent cardiologists. DISCUSSION Ischemic preconditioning was first demonstrated by Murry et al. in dog's hearts. Its work was reproduced by other authors, clearly demonstrating that brief periods of myocardial ischemia followed by reperfusion triggers cardioprotective mechanisms against subsequent and severe ischemia. On the other hand, the demonstration of ischemic preconditioning in humans requires the presence of clinical symptoms or physiological changes difficult to be measured. One methodology largely accepted are the sequential exercise tests, in which, the improvement in the time to 1.0 mm ST depression in the second of two sequential tests is considered manifestation of ischemic preconditioning.Diabetes is an important and independent determinant of clinical prognosis. It's a major risk factor for coronary artery disease. Furthermore, the association of diabetes with stable coronary artery disease imposes worse prognosis, irrespective of treatment strategy. It's still not clearly known the mechanisms responsible by these worse outcomes. Impairment in the mechanisms of ischemic preconditioning may be one major cause of this worse prognosis, but, in the clinical setting, this is not known. The present study aims to evaluate how diabetes mellitus interferes with ischemic preconditioning in patients with stable, multivessel coronary artery disease and preserved systolic ventricular function.
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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Rosa Maria Rahmi Garcia
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Augusto Hiroshi Uchida
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | | | - Thiago Luis Scudeler
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | | | | | - Cibele Larrosa Garzillo
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Gomes Lima
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | | | - Desiderio Favarato
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Priscyla Girardi
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Myrthes Takiuti
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Celia Cassaro Strunz
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Whady Hueb
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | | | - Roberto Kalil Filho
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
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Serra R, Grande R, Scarcello E, Buffone G, de Franciscis S. Angiosome-targeted revascularisation in diabetic foot ulcers. Int Wound J 2013; 12:555-8. [PMID: 24118695 DOI: 10.1111/iwj.12162] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 08/29/2013] [Indexed: 12/01/2022] Open
Abstract
Peripheral vascular disease is a common complication of type 2 diabetes and is often more severe and diffuse than in non-diabetic individuals with a higher risk of major amputations in the lower limbs. Diabetic foot revascularisation using both traditional bypass surgery and endovascular therapy are often burdened by the failure and the inevitable subsequent massive amputation. In this study, we examined the clinical response of diabetic patients with critical limb ischaemia and extended ischaemic wounds, treated with a new angiosome-based revascularisation technique. In a 3-year period, nine diabetic patients with imminent amputation threatening and foot ulcers with no feasible arterial revascularisation options were treated by the angiosome-based surgical technique by means of deep vein arterialisation. The postoperative tcPO2 evaluation showed a mean increase in the cutaneous oxygen tension in all patients treated. The overall survival rates were 88·88%, 88·88% and 77·77% at 12, 24 and 36 months, respectively. Limb salvage was 100% at 1 year and steady at 88·88% thereafter. Surgical deep venous arterialisation might be considered as an extreme alternative to attempt tissue preservation in limbs unfit for conventional arterial revascularisations. This technique would give advantages to the patients in terms of better compliance to the minor amputations and thus avoiding major limb amputations.
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Affiliation(s)
- Raffaele Serra
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Grande
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Edoardo Scarcello
- Unit of Vascular and Endovascular Surgery, Regional Hospital of Cosenza, Catanzaro, Italy
| | - Gianluca Buffone
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Stefano de Franciscis
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
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