The beneficial effect of coronary-artery-bypass surgery on survival in patients with diabetic retinopathy

Association between obstructive coronary disease and diabetic retinopathy: Cross-sectional study of coronary angiotomography and multimodal retinal imaging

AIMS

To investigate the association between diabetic retinopathy (DR) and coronary artery disease (CAD) using coronary angiotomography (CCTA) and multimodal retinal imaging (MMRI) with ultra-widefield retinography and optical coherence tomography angiography and structural domain.

METHODS

Single-center, cross-sectional, single-blind. Patients with diabetes who had undergone CCTA underwent MMRI. Uni and multivariate analysis were used to assess the association between CAD and DR and to identify variables independently associated with DR.

RESULTS

We included 171 patients, 87 CAD and 84 non-CAD. Most CAD patients were males (74 % vs 38 %, P < 0.01), insulin users (52 % vs 38 %, p < 0.01) and revascularized (64 %). They had a higher prevalence of DR (48 % vs 22 %, p = 0.01), microaneurysms (25 % vs 13 %, p = 0.04), intraretinal cysts (22 % vs 8 %, p = 0.01) and areas of reduced capillary density (46 % vs 20 %, p < 0.01). CAD patients also had lower mean vascular density (MVD) (15.7 % vs 16.5,%, p = 0.049) and foveal avascular zone (FAZ) circularity (0.64 ± 0.1 vs 0.69 ± 0.1, p = 0.04). There were significant and negative correlations between Duke coronary score and MVD (r = -0.189; p = 0.03) and FAZ circularity (r = -0,206; p = 0.02). CAD, DM duration and insulin use independently associated with DR.

CONCLUSIONS

CAD patients had higher prevalence of DR and lower MVD. CAD, DM duration and insulin use were independently associated with DR.

Diabetes complications and adverse health outcomes after coronary revascularization

AIMS

To examine effects of diabetes complications on health outcomes following coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI), comparing outcomes for patients with diabetes complications to those without diabetes complications.

METHODS

Retrospective analysis of discharge data for 61,566 patients with diabetes age 45 or older who had CABG or PCI in 2007 in United States community hospitals, using data from the Nationwide Inpatient Sample. Analysis included propensity score-adjusted logistic regression.

RESULTS

Of all patients, 21.2% of the weighted sample had diabetes complications. Older patients, Blacks and Hispanics, and those with greater illness severity were more likely to have diabetes complications. Unadjusted rates of in-hospital mortality, postoperative stroke, and renal failure were higher for patients with diabetes complications (rate ratios 2.2, 1.8, and 9.8, respectively; all p<0.0001). In adjusted results, having diabetes complications was associated with higher odds of in-hospital mortality (odds ratio, OR 1.62, 95% confidence interval, CI 1.37-1.91) and renal failure (OR 3.03, CI 1.71-5.39). Compared to CABG, PCI was associated with extra risk of postoperative renal failure for those with diabetes complications.

CONCLUSION

Among patients with diabetes having revascularization, those with diabetes complications have higher risks of in-hospital death and renal failure irrespective of having CABG or PCI.

Detecting occult coronary artery disease followed by early coronary artery bypass surgery in patients with diabetic retinopathy: report from a diabetic retinocoronary clinic

OBJECTIVES

We hypothesized that a large number of patients with diabetic retinopathy who could benefit greatly from early coronary artery bypass grafting would not be identified.

METHODS

Patients with diabetic retinopathy receiving ophthalmologic care as outpatients in our hospital in whom coronary artery disease was not previously suspected were referred randomly to the diabetic retinocoronary clinic and were asked to participate in diagnostic tests, including an exercise treadmill test and exercise thallium scintigraphy or coronary computed tomography. Patients who had type 1 diabetes mellitus, required hemodialysis, or both were excluded from this study. A definitive diagnosis of coronary artery disease was confirmed by means of coronary angiography.

RESULTS

Of 214 patients with diabetic retinopathy, 55 (25.7%) were confirmed as having significant stenotic coronary artery disease. Patients with angiographically confirmed coronary disease were older than those with negative results on diagnostic tests (62.2 + or - 9.8 vs 57.9 + or - 10.3 years, P = .01). Fifteen had 1-vessel disease, 17 had 2-vessel disease, 14 had 3-vessel disease, 1 had left main trunk plus 1-vessel disease, 2 had left main trunk plus 2-vessel disease, and 5 had left main trunk plus 3-vessel disease. Eight patients had left main trunk disease, and 18 patients with non-left main trunk disease had proximal left anterior descending coronary artery (LAD) disease. Forty-two patients showed indications of coronary revascularization (coronary artery bypass grafting in 17 and percutaneous coronary intervention in 25). During the entire follow-up (287.6 + or - 183.2 days) of 39 patients undergoing coronary revascularization, all were alive without myocardial infarction, but 8 experienced vitreous hemorrhage.

CONCLUSIONS

Approximately 25% of patients with diabetic retinopathy receiving ophthalmologic care as outpatients have a significant stenotic coronary artery disease. Of the total diabetic population, a large number of patients with diabetic retinopathy who show strong indications for early coronary artery bypass grafting might well go unrecognized.

In early-stage diabetic retinopathy, risk of cardiac events after implantation of sirolimus-eluting stent is higher than after coronary artery bypass surgery

BACKGROUND

Patients with diabetic retinopathy (DR) have an increased risk of death from coronary heart disease and myocardial infarction. The purpose of this study was to compare the outcomes of revascularization strategies (sirolimus-eluting stent [SES] and coronary artery bypass surgery [CABG]) in patients with DR according to the stage of retinopathy: non-proliferative retinopathy (NPDR) and proliferative retinopathy (PDR).

METHODS

From April 2004 until February 2007, 627 patients including 51 NPDR and 62 PDR patients underwent SES implantation. For each retinopathy group, a historical comparison group at the same stages of retinopathy undergoing CABG was selected. Cardiac events were defined as a composite of cardiac death, myocardial infarction, and repeat revascularization.

RESULTS

The average follow-up from the time of the initial revascularization was 27.7 ± 8.5 months for NPDR-SES patients, 69.6 ± 36.6 months for NPDR-CABG patients, 26.4 ± 9.7 months for PDR-SES patients, and 68.3 ± 44.2 months for PDR-CABG patients; and Kaplan-Meier estimates of the percentages of events at 24 months were 47.0%, 22.8%, 28.5%, and 26.0%. Kaplan-Meier curves for cardiac events differed significantly between the SES group and the CABG group in NPDR patients (p = 0.04), whereas the curves did not differ significantly between the two groups of PDR patients. The adjusted hazard ratio of SES implantation for cardiac events in the entire group of DR patients was 1.75 (95% confidence interval [CI] 1.02-3.00, p = 0.04).

CONCLUSIONS

SES implantation is not a suitable method of revascularization in DR patients, especially in NPDR patients. CABG may become the first-choice revascularization technique for these patients.