0 0.3 0.6 0.9 1.2 1.5 1.8 2.1 ln-segment minimal luminal diameter
FIGURE 1 Cumulative frequency distribution curves for minimal luminal diameter in the group that received sirolimus-eluting stent and in the group that received standard stent before and immediately after the intervention and at 270 days. Bare-metal stents had higher restenosis rate (arrow).
cell proliferation and migration and reduce intimal proliferation after vascular injury. The potential efficacy of thiazolidinediones to reduce restenosis was evaluated in a randomized trial of 54 patients with type 2 diabetes who underwent PCI with bare-metal stents (14). Pioglitazone (30 mg once daily) reduced compared to controls the late lumen loss (0.30 vs. 1.43 mm) and the binary angiographic restenosis (8 vs. 57%) at six months significantly. Similar results have been shown with rosiglitazone (15). Glycoprotein (GP) Ilb/IIIa inhibitors reduce the risk of ischemic complications in most patients undergoing coronary artery stenting, including those with an acute coronary syndrome and higher risk patients with stable angina. ISARSWEET randomly assigned 701 diabetic patients (16) who were undergoing elective PCI to abciximab plus heparin or placebo plus heparin with additional clopidogrel treatment. The primary endpoint of death or myocardial infarction (MI) at one year was similar in both groups (8.3 vs. 8.6% with placebo); there was also no difference in mortality at one year (4.8 vs. 5.1%). However, follow-up angiography found a moderately reduced rate of angiographic restenosis with abciximab (29 vs. 38 % with placebo).
Short- and long-term survival after CABG is significantly reduced in diabetic patients (17,18). In several large observational studies, diabetic patients had higher mortality rates at 30 days (5 vs. 2.5 %) (17), at five years (22 vs. 12%), and at 10 years (and 50 vs. 29 %) (18). Reasons for this observation include differences in the comorbidities of diabetic and non-diabetic patients undergoing CABG. For example, diabetic patients are generally older, have more severe three vessel disease, lower ejection fraction, and more often proteinuria, which are all independent risk factors for cardiovascular complications and death (19).
Most randomized trials comparing PTCA with CABG have reported similar overall outcomes for these two revascularization methods. However, subgroup analysis of randomized trials and prospective nonrandomized studies suggest that diabetes may be an exception, as the outcome is better after CABG, particularly in patients with three vessel disease (20-22). This was demonstrated by the BARI trial (21,23). Among diabetic patients CABG was associated with a significantly higher survival rate compared to PTCA at 5.4 years (81 vs. 66 %) (21) and at seven years (76 vs. 56 %) (24). The difference was entirely due to a lower cardiac mortality in the CABG group (5.8 vs. 20.6% for PTCA at 5.4 years) (23). The cardiac mortality was 2.9% when at least one internal mammary graft was used. Diabetic patients who have undergone CABG may have a better outcome after a subsequent MI than those who have undergone PTCA or were
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