Abstract
Coronary artery disease in patients with diabetes mellitus (DM) is characterized by
extensive atherosclerosis, longer lesions, and diffuse distal disease. Consequently,
these patients have worse outcomes after coronary revascularization, regardless of
the modality used. Traditionally, coronary artery bypass grafting (CABG) has been
regarded as more effective than percutaneous coronary intervention (PCI) in patients
with DM, likely because of more complete revascularization and protection against
disease progression in the bypass segment. Revascularization with balloon angioplasty,
bare-metal stents, and first-generation drug-eluting stents have all been shown to
be inferior to CABG in patients with DM. Current professional society guidelines reflect
these findings, strongly recommending CABG over PCI in this setting. Newer stent platforms,
however, have challenged this notion. The use of thinner struts, biocompatible polymer
coating, and newer antiproliferative agents have improved the rates of cardiovascular
events in patients with DM revascularized percutaneously. Since the publication of
current guidelines, new studies suggested acceptable outcomes in patients with DM
revascularized with second-generation drug-eluting stents, even though these conclusions
are drawn from small subgroup analyses or nonrandomized studies. Robust registry data
suggest similar mortality with lower rates of stroke after PCI compared with surgery,
at the expense of increased rates of repeat revascularization. If complete revascularization
can be achieved, similar rates of myocardial infarction are also observed. Therefore,
contemporary revascularization in patients with DM with multivessel coronary artery
disease should involve a multidisciplinary approach, in which interventional cardiologists
and cardiac surgeons involve their patients to individualize treatment choices, and
balance the risks and effectiveness of each modality.
Résumé
Chez les patients atteints de diabète sucré, les coronaropathies sont caractérisées
par une athérosclérose étendue, des lésions plus longues et une maladie distale diffuse.
C’est pourquoi ces patients obtiennent les pires résultats à la suite d’une revascularisation
coronarienne, quelle que soit la méthode utilisée. En général, le pontage aortocoronarien
(PAC) est considéré comme plus efficace que l’intervention coronarienne percutanée
(ICP) chez les patients atteints de diabète sucré, probablement en raison de la revascularisation
plus complète et de la protection contre l’évolution de la maladie dans le segment
ayant subi le pontage. La revascularisation avec angioplastie à ballonnet, les endoprothèses
non médicamentées et les endoprothèses médicamentées de première génération se sont
toutes avérées inférieures au PAC chez les patients atteints de diabète sucré. Les
lignes directrices actuelles des organismes professionnels tiennent compte de ces
résultats et recommandent vivement un PACG plutôt qu’une ICP dans ce contexte. Cependant,
les nouveaux types d’endoprothèses ont incité la remise en question de cette recommandation.
En effet, l’utilisation de mailles plus minces, de revêtement en polymère biocompatible
et des nouveaux agents antiprolifératifs a permis d’améliorer les taux d’événements
cardiovasculaires chez les patients atteints de diabète sucré qui subissent une revascularisation
par voie percutanée. Depuis la publication des lignes directrices actuelles, de nouvelles
études ont fait état d’issues acceptables chez les patients atteints de diabète sucré
qui subissent une revascularisation avec des endoprothèses médicamentées de deuxième
génération, bien que ces conclusions soient tirées d’analyses de petits sous-groupes
ou d’études sans répartition aléatoire. Des données de registre solides semblent indiquer
un taux de mortalité similaire et des taux inférieurs d’AVC après une ICP comparativement
à une intervention chirurgicale, mais les taux de revascularisation secondaire restent
élevés. S’il est possible d’obtenir une revascularisation complète, des taux similaires
d’infarctus du myocarde sont également observés. Par conséquent, chez les patients
présentant un diabète sucré et une coronaropathie de plusieurs vaisseaux, la revascularisation
doit actuellement faire appel à une approche pluridisciplinaire au sein de laquelle
les cardiologues interventionnels et les chirurgiens cardiaques font participer leurs
patients aux prises de décisions en matière de traitement personnalisé, en tenant
compte des risques et de l’efficacité de chaque modalité.
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Article info
Publication history
Published online: February 23, 2018
Accepted:
February 19,
2018
Received:
October 31,
2017
Footnotes
See page 661 for disclosure information.
Identification
Copyright
© 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
