Revascularization Strategies in Patients With Type 2 Diabetes
Revascularization Strategies in Patients With Type 2 Diabetes
This review aims to describe new developments in coronary revascularization strategies for patients with pre-existing Type 2 diabetes mellitus (DM). Recommended strategies for revascularization have been an active area of study with recent important developments. In patients with Type 2 DM and multivessel coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery is the preferred method for revascularization. Patients with DM are at increased risk for diffuse cardiovascular disease due to the proinflammatory, prothrombotic effects of chronic hyperglycemia. In patients undergoing percutaneous coronary intervention, drug-eluting stents and more potent antiplatelet agents especially in those presenting with acute coronary syndromes should be employed.
Diabetes mellitus (DM) is a metabolic condition that imposes a substantial burden on those it afflicts. The multiple metabolic derangements associated with diabetes, including the proinflammatory effects of hyperglycemia and insulin resistance may contribute to endothelial and vascular smooth muscle dysfunction. Diabetes induces a prothrombotic state in multiple ways in that platelet function is altered because platelets exhibit increased adhesion, activation and aggregation. Moreover, both plasma- and lesion-based coagulation factor expression is increased, while endogenous anticoagulants are downregulated. Combined, these factors clinically translate into a two- to fourfold increased risk for diabetics to develop coronary artery disease (CAD).
The atherosclerotic disease burden was so great that the risk of experiencing a cardiovascular event was comparable among diabetics who had never had an event as for non-diabetics who had a prior myocardial infarction (MI). As such, it is considered equivalent to that of CAD. Diabetics are disproportionately represented among patients with cardiovascular disease (CVD). While they comprise 8% of the general population, they account for up to 25% of patients who receive revascularization. Although cardiovascular mortality rates have declined overall in the USA, this trend has not extended to the DM subset of patients and moreover, they tend to experience more severe clinical CAD outcomes. Patients who present with unstable angina (UA) are more likely to progress to MI, and DM patients presenting with MI are more likely to die than non-diabetics. In a large, multicenter study, DM patients with CAD were found to have significantly lower mortality at 1 year if they received revascularization compared with those who did not as well as when they received evidence-based medical therapy though there is evidence to suggest that these therapies may be underutilized in this population. Determining the optimal treatment strategy for CAD in DM patients is a continuously and rapidly evolving area of research. Here, we will review the relevant clinical trials and present several new and exciting developments.
Abstract and Introduction
Abstract
This review aims to describe new developments in coronary revascularization strategies for patients with pre-existing Type 2 diabetes mellitus (DM). Recommended strategies for revascularization have been an active area of study with recent important developments. In patients with Type 2 DM and multivessel coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery is the preferred method for revascularization. Patients with DM are at increased risk for diffuse cardiovascular disease due to the proinflammatory, prothrombotic effects of chronic hyperglycemia. In patients undergoing percutaneous coronary intervention, drug-eluting stents and more potent antiplatelet agents especially in those presenting with acute coronary syndromes should be employed.
Introduction
Diabetes mellitus (DM) is a metabolic condition that imposes a substantial burden on those it afflicts. The multiple metabolic derangements associated with diabetes, including the proinflammatory effects of hyperglycemia and insulin resistance may contribute to endothelial and vascular smooth muscle dysfunction. Diabetes induces a prothrombotic state in multiple ways in that platelet function is altered because platelets exhibit increased adhesion, activation and aggregation. Moreover, both plasma- and lesion-based coagulation factor expression is increased, while endogenous anticoagulants are downregulated. Combined, these factors clinically translate into a two- to fourfold increased risk for diabetics to develop coronary artery disease (CAD).
The atherosclerotic disease burden was so great that the risk of experiencing a cardiovascular event was comparable among diabetics who had never had an event as for non-diabetics who had a prior myocardial infarction (MI). As such, it is considered equivalent to that of CAD. Diabetics are disproportionately represented among patients with cardiovascular disease (CVD). While they comprise 8% of the general population, they account for up to 25% of patients who receive revascularization. Although cardiovascular mortality rates have declined overall in the USA, this trend has not extended to the DM subset of patients and moreover, they tend to experience more severe clinical CAD outcomes. Patients who present with unstable angina (UA) are more likely to progress to MI, and DM patients presenting with MI are more likely to die than non-diabetics. In a large, multicenter study, DM patients with CAD were found to have significantly lower mortality at 1 year if they received revascularization compared with those who did not as well as when they received evidence-based medical therapy though there is evidence to suggest that these therapies may be underutilized in this population. Determining the optimal treatment strategy for CAD in DM patients is a continuously and rapidly evolving area of research. Here, we will review the relevant clinical trials and present several new and exciting developments.