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J Am Coll Cardiol, 2005; 45:464-466, doi:10.1016/j.jacc.2004.11.005
© 2005 by the American College of Cardiology Foundation
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CORRESPONDENCE: RESEARCH CORRESPONDENCE

Impact of microvascular complications on outcome after coronary stent implantations in patients with diabetes

Carlo Briguori, MD, PhD*, Gerolama Condorelli, MD, PhD, Flavio Airoldi, MD, Fiore Manganelli, MD, Anna Violante, MD, Amelia Focaccio, MD, Bruno Ricciardelli, MD and Antonio Colombo, MD, FACC

* Laboratory of Interventional Cardiology, Clinica Mediterranea, Via Orazio, 2, 80122 Naples, Italy (Email: briguori.carlo{at}hsr.it).

To the Editor: Bare metal stent implantation is less effective in patients with diabetes than in patients without diabetes (1–3). Microvascular complications have been identified as risk markers for cardiovascular events in patients with diabetes (4–7). We evaluated the impact of microvascular complications (nephropathy and retinopathy) on the outcome after elective coronary bare metal stent implantation in patients with type 2 diabetes.

A total of 283 consecutive patients with type 2 diabetes mellitus who successfully underwent their first elective bare metal stent implantation at our institution from January 2000 to June 2003 were included into the analysis. Diabetic retinopathy was detected within one week before or after the procedure. Microalbuminuria (protein excretion of 30 to 300 mg/24 h) was determined the day before the procedure.

The principal characteristics of the 283 patients are summarized in Table 1. At 12 months, major adverse cardiac events (major adverse clinical event [MACE], i.e., death of any cause, nonfatal myocardial infarction, repeat percutaneous procedure, and bypass surgery) occurred in 34 of the 161 patients (21%) in the group without microvascular complications, in 18 of the 45 patients (40%) in the nephropathy group, in 22 of the 43 patients (51%) in the retinopathy group, and in 25 of the 34 patients (73.5%) in the group with both microvascular complications (p < 0.001) (Fig. 1). The influence of clinical, angiographic, and procedural variables on MACE at follow-up was evaluated with a Cox regression analysis. Variables entered into the model were as follows: the presence of microvascular complications (as defined group without microvascular complications, group with nephropathy, group with retinopathy, and group with both microvascular complications), age ≥70 years, sex, insulin-treatment, duration of diabetes >7 years, small (≤2.75 mm) vessel, complex (B2/C) lesions, elective IIb/IIIa inhibitors, left ventricular ejection fraction ≤40%, complete revascularization, unstable angina, and multivessel stenting. Independent predictors of MACE at follow-up were as follows: the presence of diabetic nephropathy (hazard ratio [HR] = 1.96; 95% confidence interval [CI] = 1.03 to 3.73; p = 0.039), presence of diabetic retinopathy (HR = 3.38; 95% CI = 1.73 to 6.60; p < 0.001), presence of both diabetic microvascular complications (HR = 6.28; 95% CI = 3.33 to 11.84; p <0.001), insulin treatment (HR = 1.78; 95% CI = 1.09 to 2.92; p = 0.021), and complete revascularization (HR = 0.57; 95% CI = 0.37 to 0.96; p = 0.019).


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  		Table 1. Characteristics of Patients According to the Presence of Microvascular Complications
 


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  		Figure 1 Kaplan-Meier event-free survival at 12 months in four groups defined according to the presence of microvascular complications.

 
Patients with type 2 diabetes mellitus and proteinuria or retinopathy have an increased risk of cardiovascular death (4–7). The relative risks of cardiovascular mortality and morbidity associated with the presence of microalbuminuria differ markedly according to the presence or absence of retinopathy (7). In the present study, we found that microvascular complications represent a strong predictor of MACE after bare stent implantation in type 2 diabetic patients. In particular, the presence of both nephropathy and retinopathy identifies a subgroup of diabetic patients with a worse one-year outcome after elective bare stent implantation. The results of the present study confirm and extend previous observations (8,9). Screening patients with diabetes for both nephropathy and retinopathy before coronary procedures appears to be an effective way to risk-stratify this group of patients and thus to focus preventive measures. In the era of drug-eluting stent implantation, these findings may be important to better interpret results and to appropriately stratify patients undergoing percutaneous or surgical treatments in prospective randomized trials.


   References
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