Special Considerations in Diabetic Patients

Compared with nondiabetic patients, patients with diabetes often have a more advanced coronary atherosclerosis with diffuse disease in small-lumen vessels. With any treatment modality for coronary revascularization, diabetic patients have an inferior outcome compared with nondiabetics. This was first shown for CABG. In patients with diabetes mellitus, CABG is associated with a more rapid progression of atherosclerosis of both grafted and nongrafted vessels, as well as an accelerated degeneration of venous bypass grafts, compared with nondiabetics. Nevertheless, CASS demonstrated that in older diabetics coronary revascularization confers a substantial benefit compared with lone medical therapy.52 Likewise, PCI in patients with diabetes is associated with a substantially increased risk of adverse short-term and long-term outcome compared with PCI in non-diabetics. In particular, it the risk of restenosis after any type of PCI is substantially increased in diabet-ics.53,54 Moreover, whereas restenosis has little impact on survival in patients without diabetes, Bertrand and coworkers demonstrated that restenosis after plain balloon angioplasty in diabetics has a major impact on 10-year mortality, with a 45% relative increase for nonocclusive stenosis and more than a twofold increase with occlusive stenosis.55 The risk of peri-interventional death and MI is also increased by about twofold after plain balloon angioplasty in diabetics compared with nondiabetics.56

Because coronary revascularization in diabetics differs in many aspects from that in nondiabetics, the indications for PCI in diabetics deserve special attention.

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