PCI in Patients with Diabetes Mellitus

1
PCI in Patients with Diabetes Mellitus
2nd August, 2007
Robaayah Zambahari FRCP, FACC, FAPSIC, FNHAM,
FAsCC Institut Jantung Negara (National Heart
Institute), Kuala Lumpur, Malaysia
2
NCVD PCI Registry, Malaysia
3
National Heart Institute (IJN), Kuala Lumpur,
Malaysia
4
NCVD-PCI Registry 2007 (up to 15th June)
Total PCI 1249 Diabetics 535 (42.8)
399 48.7
326 39.8
83 10.1
32 1.5
5
National Heart Institute (IJN), Kuala Lumpur,
Malaysia
6
Issues in PCI in Diabetics
Coronary Artery Disease in Diabetics
Coronary Arteries tend to be small
Involvement tends to be diffuse
Atherosclerosis tends to be more progressive ?
newer lesions ??TVR
Lesions tend to be more complex
7
Issues in PCI in Diabetics
Biologic Response to Diabetes Mellitus
Higher thrombogenicity
8
Issues in PCI in Diabetics
In chronic Diabetics, maybe renal nephropathy,
may aggravate contrast nephropathy
9
Issues in PCI in Diabetics
Nature of diabetic vessel / lesion ?Thrombogenicit
y
Higher risk profile
More frequent procedural complications
Outcomes worse than non-diabetics
Higher rates of restenosis ? occlusive
restenosis, Higher TVR
Higher rates of stent thrombosis
10
Issues in PCI in Diabetics
Risk even greater in insulin-dependent Diabetics
Risk even greater in poorly-controlled Diabetics
11
Glycemic Control and TVR in Diabetic Patients
Incidence of TVR in Diabetics Non Diabetic
Patients
Corpus et al, JACC, 2004 43 8
12
Issues in PCI in Diabetics
Issues with antithrombotic drug therapy
Diabetics more likely to be resistant to Aspirin
or to both Aspirin Clopidogrel
GP IIbIIIa-inhibitors conferred benefit in PCI of
diabetics
13
GP IIbIIIa Interventional Trials
30-day Death, MI or Urgent Revascularization
14
Effect of Abciximab on 1-year Mortality
Consistent benefit in all groups in EPIC, EPILOG
EPISTENT trials
15
(No Transcript)
16
Issues in PCI in Diabetics
Diabetes DESs
SIRIUS and TAXUS showed significant benefit with
use of DESs
17
SIRIUS Trial
TAXUS-IV Trial
Stone et al, NEJM 2004 350221
Moses et al, NEJM 2003 3491315
18
Issues in PCI in Diabetics
Multi vessel stenting compared to CABGS
Previous trials suggested a more favourable
outcome with CABGS
The gap of benefit had narrowed with DESs.
Common limitations of the earlier trials
Diabetic status lack of information on
anti diabetic therapy, glycemic
status duration of Diabetes, the control
of diabetes
Would better control of Diabetes ? or abolish
the benefit of CABGS?
19
Issues in PCI in Diabetics
Multi vessel stenting compared to CABGS
Being addressed in BARI 2D CARDIA (Coronary
Artery Revascularization in
DIAbetics) FREEDOM (Future Revascularization
Evaluation in patients with
Diabetics Opimal
Management of multivessel disease)
20
BARI II-D Trial
21
Following results of other devices in relation of
PCI in general and in PCI in Diabetics
Bioengineered Antibody-trapping Genous
stent e-Healing Registry
Stents dedicated for small vessels CardioMindTM
Sparrow Coronary Stent
22
Issues in PCI in Diabetics
Multi vessel stenting compared to CABGS
Based on currently available data, for now PCI
probably for 1 or 2-vessel
disease discrete lesions without diffuse
disease high risk for CABGS
23
Issues in PCI in Diabetics
In performing PCI in Diabetics
Consider Use of DES, Use of GP
IIbIIIa-inhibitor Optimize Diabetes
control Other Medications Statins
ACE-inhibitors / ARB
24
THANK YOU