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Canadian Journal of Cardiology

The Potential Effects of New Stent Platforms for Coronary Revascularization in Patients With Diabetes

Published:February 23, 2018DOI:https://doi.org/10.1016/j.cjca.2018.02.020

      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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