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1. Ilb/IIIa Inhibitors and PCI |

As noted above, abciximab was shown in EPISTENT to preserve the benefit of ยง

stenting in diabetic patients by reducing the target vessel revascularization by over 50% compared to placebo (51). In addition, abciximab decreased the 1-year Ja mortality of diabetic patients when data from three placebo-controlled trials were pooled, suggesting that abciximab therapy should be strongly considered in all

& u diabetic patients undergoing PCI with or without stent implantation (52). In this study, mortality in diabetics who underwent multivessel PCI was reduced from 7.7% to 0.9%; p = 0.018 with abciximab use and mortality in insulin-treated diabetics was decreased from 8.1% to 4.2%; p = 0.073. A recently reported subgroup analysis from EPISTENT indicated that diabetic women, who have a higher risk of death or MI after PCI, experienced a dramatic reduction in mortality, MI, or TVR at 1 year when treated with stent and abciximab compared to stent alone or balloon with abciximab (53). The mortality in the stent + abciximab arm was zero (compared to 7.7% with stent + placebo; p < 0.06 and 4.4% with balloon + abciximab; p = 0.10). The rate of death/MI/TVR with stent + abciximab was 13.3% (compared to 34.5% and 28.9%, respectively, both p < 0.04) and the TVR was 4.5% (compared to 21.4% and 26.7%, respectively; both p = 0.02). The complementary long-term benefit of stents and abciximab make a strong case for their routine use in diabetic patients during PCI, especially when the patient is female, insulin-dependent, and/or undergoing multivessel PCI.

2. Thienopyridines, PCI, and CABG

The ADP receptor antagonists clopidogrel and ticlopidine when used in conjunction with aspirin reduce complications of stenting compared to aspirin alone and aspirin plus warfarin (58,59). Ticlopidine pretreatment before coronary stenting is associated with sustained decrease in adverse cardiac events compared with ticlopidine administered post-PCI (60). Because of fewer side effects and equal or superior efficacy, clopidogrel has become standard antiplatelet therapy for prophylaxis during PCI (58-61). Its potency has been evidenced in trials comparing it with ticlopidine and also when emergency CABG is complicated by bleeding, or clopidogrel is stopped due to side effects a few days after stent implantation leading to stent thrombosis, and with the observation that prolonged therapy exceeding 6 months prevents late-late thrombosis following stent implantation and brachytherapy. The recently reported CURE trial showing benefit of clopidogrel in acute coronary syndromes has heightened interest in the more generalized use of this agent. Its relative value in the diabetic undergoing PCI has not been thoroughly tested. Given the prothrombotic milieu typical of the diabetic patient, clopidogrel must be viewed as a very important adjunctive therapy that should be initiated as early before PCI as possible and maintained until endothelialization of the coronary stent has occurred. When used in patients after CABG, clopido-grel has been shown to be more effective than aspirin, resulting in a 43% reduction in vascular death (p = 0.03) (63).

3. Glycemic Control After Revascularization

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