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Canadian Journal of Cardiology

Urgent Revascularization Strategies in Patients With Diabetes Mellitus and Acute Coronary Syndrome

Published:March 19, 2019DOI:https://doi.org/10.1016/j.cjca.2019.03.010

      Abstract

      The prevalence of diabetes mellitus (DM) is rising globally and in Canada. Besides being a risk factor for the development of coronary artery disease, DM is also a marker of poor prognosis in patients with acute coronary syndrome (ACS), increasing the risks for ischemic and bleeding complications. Patients with DM have a high prevalence of multivessel coronary artery disease (MVD) and robust evidence has supported coronary artery bypass surgery (CABG) as the optimal revascularization strategy in the setting of stable ischemic heart disease. In the acute scenario, particularly in patients with non–ST-segment elevation (NSTE) ACS (NSTE-ACS), there are many uncertainties regarding the best revascularization strategy. Most guidelines suggest an invasive and timely approach (that is, performing coronary catheterization within 72 hours after the onset of the NSTE-ACS) and make recommendations about choosing between percutaneous coronary intervention (PCI) or CABG on the basis of data for patients with stable ischemic heart disease. Recent observational and subgroup analyses suggest that CABG might be the preferential method of revascularization for patients with DM and MVD also in the NSTE-ACS setting; however, dedicated randomized clinical trials are lacking. Finally, in patients who present with an ST-segment elevation myocardial infarction, the initial revascularization method of choice is generally PCI, instead of fibrinolysis or CABG, and DM status most often does not influence this decision. The management of residual MVD after primary PCI for ST-segment elevation myocardial infarction, however, remains controversial.

      Résumé

      La prévalence du diabète est en hausse tant dans le monde qu'au Canada. En plus d'être un facteur de risque de coronaropathie, le diabète est aussi un marqueur de pronostic défavorable chez les patients atteints du syndrome coronarien aigu (SCA) car il augmente les risques de complications ischémiques et hémorragiques. Chez les patients diabétiques, la prévalence de la coronaropathie plurivasculaire (CPV) est élevée, et des données probantes fiables montrent que le pontage aortocoronarien (PAC) est la stratégie de revascularisation optimale dans les cas de cardiopathie ischémique stable. Dans le scénario de la forme aiguë, en particulier chez les patients présentant un SCA sans élévation du segment ST (SCA-SSDST), de nombreuses incertitudes entourent le choix de la meilleure stratégie de revascularisation. La plupart des lignes directrices suggèrent une approche invasive et rapide (c'est-à-dire une coronarographie dans les 72 heures suivant l'apparition du SCA-SSDST) et font des recommandations sur le choix entre l'intervention coronarienne percutanée (ICP) et le PAC qui s'appuient sur des données portant sur des patients dont la cardiopathie ischémique est stable. Des analyses observationnelles et par sous-groupe récentes laissent croire que le PAC pourrait être la méthode de choix pour la revascularisation chez les patients atteints de diabète et de CPV dans le contexte d'un SCA-SSDST; toutefois, aucun essai clinique portant sur cette question n'a encore été mené. Finalement, chez les patients ayant subi un infarctus du myocarde avec élévation du segment ST, la méthode de choix de la revascularisation initiale est en général l'ICP plutôt que la fibrinolyse ou le PAC, et dans la plupart des cas, la présence ou l'absence de diabète n'a pas d'influence sur cette décision. Toutefois, la question de la prise en charge de la CPV résiduelle après une ICP primaire pour un infarctus du myocarde avec sus-décalage du segment ST fait toujours l'objet de controverses.
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