Kantonsspital St.Gallen

Diabetes : Patient Selection

Michael Brändle

abstract KEY POINTS
• Diabetes confers an equivalent cardiovascular risk to ageing 15 years.
• Diabetes-associated deaths − 2/3 of them being cardiovascular − are on an exponential rise following the diabetes “epidemics” observed in Western countries.
• Although mortality rates from CAD have declined in the Western world during the past 30 years and diabetic individuals have also benefited from the decline, the more than twofold higher risk of dying from CAD in men and women with diabetes has persisted over time.
• CAD is more prevalent, more severe, and occurs at younger age in patients with diabetes. Chronic hyperglycemia, dyslipidemia, and insulin resistance have been associated with an accelerated form of atherogenesis, characterized by a prothrombotic state, enhanced inflammation, and endothelial dysfunction.
• Diabetic patients undergoing coronary revascularization have worse outcomes − both in the setting of PCI and CABG − than nondiabetic individuals. PCI with first generation DES and CABG appear to have comparable mid-term results in diabetic patients with multivessel disease in terms of death, MI, or stroke. Conversely, surgery remains superior to PCI for repeat revascularization.
• Diabetic patients with both non-ST-elevation ACS and STEMI have higher short- and long-term morbidity and mortality rates than nondiabetic counterparts. However, they derive a grater benefit from aggressive management, including early invasive strategy, potent platelet inhibition and primary angioplasty.
• The evidence for a CV benefit of intensive glycemic control primarily rests on long-term follow-up of study cohorts treated early in the course of type 1 and type 2 diabetes as well as subset analyses of several large interventional trials.
• The risks of aggressive glycemic control may outweigh the benefits in some diabetic patients, such as those with very long duration of diabetes, known history of severe hypoglycemia, poor glycemic control, advanced atherosclerosis, and advanced age or frailty.
• Aggressive modification of additional risk factors, including blood pressure and cholesterol level control, cigarette smoking cessation, weight loss, and exercise remain key of cardiovascular prevention in diabetic individuals.
citation Brändle M (2011). Diabetes: Patient Selection. In Textbook of Interventional Cardiology (pp. 30-50). Philadelphia: Elsevier Saunders.
type book chapter (English)
book title Textbook of Interventional Cardiology
date of publishing 2011
publisher Elsevier Saunders (Philadelphia)
volume 6th Edition
ISBN number 978-1-4377-2358-8
pages 30-50
contact Michael Brändle