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Diabetes mellitus in patients undergoing percutaneous drug-eluting stent implantation: short and long-term results. Claudio Moretti, M.D. Division of Cardiology, University of Turin, Turin, Italy on behalf of the University of Turin Registry Investigators : - PowerPoint PPT Presentation
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Diabetes mellitus in patients Diabetes mellitus in patients undergoing percutaneous drug-undergoing percutaneous drug-
eluting stent implantation: eluting stent implantation: short and long-term resultsshort and long-term results
Claudio Moretti, M.D.Claudio Moretti, M.D.Division of Cardiology, University of Turin, Turin, ItalyDivision of Cardiology, University of Turin, Turin, Italy
on behalf of the University of Turin Registry Investigators:on behalf of the University of Turin Registry Investigators:G. Longo, F. D’Ascenzo, A. Gonella, A. Pullara, G. Biondi Zoccai, G. Longo, F. D’Ascenzo, A. Gonella, A. Pullara, G. Biondi Zoccai,
F. Sciuto, P.L. Omedè, G. P. Trevi, I. SheibanF. Sciuto, P.L. Omedè, G. P. Trevi, I. Sheiban
The introduction of drug-eluting stents (DES) has markedlyThe introduction of drug-eluting stents (DES) has markedlyimproved mid-term results of percutaneous coronaryimproved mid-term results of percutaneous coronaryintervention (PCI) in diabetics. intervention (PCI) in diabetics.
Furthermore it is unclear whether the risk-benefit balanceFurthermore it is unclear whether the risk-benefit balanceof DES in diabetics is maintained also at long-term and in of DES in diabetics is maintained also at long-term and in
insulin requiring patients. insulin requiring patients.
We aimed to appraise long-term outcomes of diabeticWe aimed to appraise long-term outcomes of diabeticpatients treated with PCI with DES, stratifying according topatients treated with PCI with DES, stratifying according toinsulin therapy.insulin therapy.
Background
Methods
Patients undergoing PCI with DES from July 2002 to June 2004 at our center, and thus
eligible for at least 5-year follow-up
N=1277
non-insulin-requiring diabetics
275/1277 (22%)
without diabetes
954/1277 (75%)
insulin-requiring diabetics
37/1277 (3%)
The primary end-point was the long-term rate of majorThe primary end-point was the long-term rate of major
adverse cardiac events (MACE, ie the composite of death,adverse cardiac events (MACE, ie the composite of death,
myocardial infarction, or target vessel revascularization).myocardial infarction, or target vessel revascularization).
Secondary end-points were the individual components of Secondary end-points were the individual components of MACE, as well as death divided according to its etiology.MACE, as well as death divided according to its etiology.
We also considered stent thrombosis according to theWe also considered stent thrombosis according to the
Academic Research Consortium definitions.Academic Research Consortium definitions.
Methods
Clinical characteristics of patients
There were significant differences across groups in prevalence of male gender (respectively, 32%, 81% and 75%, p<0.001), and DES usage (54%, 34% and 30%, p=0.007).
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
male DES usage
without diabetes
non-insulin-requiringdiabetics
insulin-requiring diabetics
p< 0.001 p= 0.007
81%
75%
32%
54%
34%
30%
insulin-requiring diabetics non-insulin-requiring diabetics without diabetes
65 + 11
67 + 10
65 + 9.6
Age of patients
The mean age of patients is comparable in the three groups.
Early clinical outcomes
0%
1%
2%
3%
4%
5%
6%
7%
8%
MACE death myocardialinfarction
insulin-requiring diabetics
non-insulin-requiringdiabetics
without diabetes
p= 0.78 p= 0.71 p= 0.02
30-day MACE occurred with similar frequency in the three groups (8%, 7% and 6%, p=0.78), with death in 3%, 2%, and 1% (p=0.71) and myocardial infarction in 5%, 2% and 1% (p=0.02).
30-DAY OUTCOMES INSULIN-REQUIRING DIABETICS
NON-INSULIN-REQUIRING DIABETICS
WITHOUT DIABETICS PP
MACE 3/37 (8,.1%) 20/275 (7.3%) 60/954 (6.3%) 0.78
Death 1/37 (2.7%) 5/275 (1.8%) 13/954 (1.4%) 0.71
Sudden death 0/37 (0%) 1/275 (0.4%) 5/954 (0.5%) 086
Non-sudded ischemic death
0/37 (0%) 3/275 (1.1%) 7/954 (0.7%) 0.71
Non-ischemic cardiac death
1/37 (2.7%) 0/275 (0%) 0/954 (0%) <0.001
Non-cardiac vascular death
0/37 (0%) 0/275 (0%) 0/954 (0%) 0
Non-cardiovascular death
0/37 (0%) 1/275 (0.4%) 0/954 (0%) 0.16
Myocardial infarction 2/37 (5.4%) 5/275 (1.8%) 8/954 (0.8%) 0.02
non Q 1/37 (2.7%) 2/275 (0.7%) 5/954 (0.5%) 0.25
Q 0/37 (0%) 1/275 (0.4%) 2/954 (0.2%) 0.85
Repeat PCI 2/37 (5.4%) 10/275 (3.6%) 43/954 (4.5%) 0.78
CABG 0/37 (0%) 1/275 (0.4%) 0/954 (0%) 0.16
Stroke 0/37 (0%) 0/275 (0%) 4/954 (0.4%) 0.51
Stent thrombosis 1/37 (2.7%) 1/275 (0.4%) 9/954 (0.9%) 0.31
Definite 0/37 (0%) 0/275 (0%) 7/954 (0.7%) 0.31
Probable 1/37 (2.7%) 1/275 (0.4%) 2/954 (0.2%) 0.02
Possible 0/37 (0%) 0/275 (0%) 0/954 (0%) 0
30- days outcomes: causes of death
0%
1%
1%
2%
2%
3%
3%
no sudden-ischemicdeath
sudden death non ischemic-cardiacdeath
insulin-requiring diabetics non-insulin-requiring diabetics without diabetes
p< 0.001 p= 0.7 p= 0.9
0%
10%
20%
30%
40%
50%
60%
MACE death myocardialinfarction
repeatrevascularization
definite stentthrombosis
insulin-requiring diabetics
non-insulin-requiring diabetics
without diabetes
p< 0.001 p< 0.001 p= 0.25 p= 0.11 p= 0.78
Late clinical outcomes
After a median follow-up period of 58 months, MACE occurred in 59% of patients with insulin-requiring diabetes, in 51% of non-insulin-requiring diabetics, and in 39% of non-diabetics (p<0.001), with death in 24%, 17% and 9% (p<0.001), myocardial infarction in 11%, 7%, and 5% (p=0.25), repeat revascularization in 46%, 32%, and 30% (p=0.11), and definite stent thrombosis occurred in in 0%, 1%, and 1% (p=0.78).
LATE CLINICAL OUTCOMES INSULIN-REQUIRING DIABETICS
NON-INSULIN-REQUIRING DIABETICS
WITHOUT DIABETICS P
MACE 22/37 (59.5%) 139/275 (50.6%) 371/954 (38.9%) <0.001
Death 9/37 (24.3%) 48/275 (17.5%) 81/954 (8.5%) <0.001
Sudden death 1/37 (2.3%) 10/275 (3.6%) 18/954 (1.9%) 0.229
Non-sudden ischemic death 0/37 (0%) 9/275 (3.3%) 17/954 (1.8%) 0,206
Non-ischemic cardiac death 2/37 (5.4%) 10/275 (3.6%) 11/954 (1.5%) <0.001
Non-cardiac vascular death 0/37 (0%) 2/275 (0.7%) 10/954 (1.1%) 0.74
Non-cardiovascular death 5/37 (13.5%) 16/275 (5.8%) 35/954 (3.7%) 0.007
Myocardial infarction 4/37 (10.8%) 18/275 (6.6%) 49/954 (5.1%) 0.25
non Q 1/37 (2.7%) 9/275 (3.3%) 27/954 (2.8%) 0.93
Q 0/37 (0%) 6/275 (2.2%) 2/954 (0.2%) 0.001
Repeat PCI 17/37 (45.9%) 87/275 (31.6%) 285/954 (29.7%) 0.12
CABG 1/37 (2.7%) 9/275 (3.3%) 16/954 (1.7%) 0.25
Stroke 0/37 (2.7%) 5/275 (1.8%) 25/954 (2.6%) 0.47
Stent thrombosis 1/37 (0%) 6/275 (2.2%) 16/954 (1.6%) 0.79
Definite 0/37 (0%) 3/275 (1.1%) 12/954 (1.2%) 0.78
Probable 1/37 (2.7%) 2/275 (0.7%) 2/954 (0.2%) 0.034
Possible 0/37 (0%) 1/275 (0.4%) 2/954 (0.2%) 0.86
Late clinical outcomes: causes of death
0%
2%
4%
6%
8%
10%
12%
14%
no sudden-ischemic death
sudden death non ischemic-cardiac death
non cardiac-vascular death
non cardiac death
insulin-requiring diabetics non-insulin-requiring diabetics without diabetes
p= 0.21 p= 0.23 p< 0.001 p= 0.74 p= 0.007
This long-term retrospective study emphasizes the veryThis long-term retrospective study emphasizes the very
high risk of long-term adverse events faced by insulinhigh risk of long-term adverse events faced by insulin
requiring and non-insulin-requiring diabetics undergoingrequiring and non-insulin-requiring diabetics undergoing
PCI with DES.PCI with DES.
Further research on additional pharmacologic treatments or Further research on additional pharmacologic treatments or hybrid revascularization strategies to mitigate their hybrid revascularization strategies to mitigate their burden of morbidity and mortality is warranted.burden of morbidity and mortality is warranted.
Conclusions
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