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STATE-OF-THE-ART PAPER

Coronary Heart Disease in Patients With Diabetes

Part II: Recent Advances in Coronary Revascularization

Department of Medicine, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada.

Manuscript received July 11, 2006; revised manuscript received September 7, 2006, accepted September 11, 2006.

^_* Reprint requests and correspondence: Dr. Martial G. Bourassa, Research Center, Montreal Heart Institute, Montreal, Quebec H1T 1C8, Canada. (Email: martial.bourassa{at}icm-mhi.org).

Although diabetic patients represent approximately one-quarter of all those undergoing revascularization, their outcomes after revascularization are usually worse compared with non-diabetic patients. We examined the recent advances in percutaneous and surgical revascularization that are relevant to the treatment of diabetic patients. A systematic review of publications in the past 5 years (2000 to 2005) relating to coronary revascularization in diabetes was undertaken. Early and mid-term follow-up of diabetic patients after revascularization indicates that the incidence of myocardial infarction and repeat revascularization are reduced in surgically treated patients compared with those treated by balloon angioplasty alone. Percutaneous coronary intervention (PCI) with bare metal stents has reduced the surgical advantage (for reintervention) in the early–mid-term; however, repeat revascularization in diabetic patients continues to be substantially higher after PCI. Advances in PCI include the use of drug-eluting stents and adjunctive drug therapies, such as abciximab. Glycemic control is an important determinant of outcome after revascularization in diabetic patients, and the impact of tight glycemic control after PCI is currently being investigated in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 in Diabetes). Improvements in PCI and coronary artery bypass graft surgery are leading to better results in diabetic patients, and clinical trials are presently comparing contemporary PCI with surgery.

Abbreviations and Acronyms   BMI = body mass index   BMS = bare-metal stent   CABG = coronary artery bypass grafting   CHD = coronary heart disease   CI = confidence interval   CKMB = creatine kinase isoenzyme MB   DES = drug-eluting stent   DM = diabetes mellitus   IMA = internal mammary artery   LAD = left anterior descending   LMS = left main stem   MACCE = major adverse cardiac and cerebrovascular events   MI = myocardial infarction   OR = odds ratio   PCI = percutaneous coronary intervention   PTCA = percutaneous transluminal coronary angioplasty   RR = relative risk   SES = sirolimus-eluting stent   SVG = saphenous vein graft   TLR = target lesion revascularization   TVR = target vessel revascularization

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