Evolution of percutaneous coronary intervention in patients with diabetes: a report from the National Heart, Lung, and Blood Institute-sponsored PTCA (1985-1986) and Dynamic (1997-2006) Registries

Abstract

Objective: To evaluate the association of successive percutaneous coronary intervention (PCI) modalities with balloon angioplasty (BA), bare-metal stent (BMS), drug-eluting stents (DES), and pharmacotherapy over the last 3 decades with outcomes among patients with diabetes in routine clinical practice.

Research design and methods: We examined outcomes in 1,846 patients with diabetes undergoing de novo PCI in the multicenter, National Heart, Lung, and Blood Institute-sponsored 1985-1986 Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry and 1997-2006 Dynamic Registry. Multivariable Cox regression models were used to estimate the adjusted risk of events (death/myocardial infarction [MI], repeat revascularization) over 1 year.

Results: Cumulative event rates for postdischarge (31-365 days) death/MI were 8% by BA, 7% by BMS, and 7% by DES use (P = 0.76) and for repeat revascularization were 19, 13, and 9% (P < 0.001), respectively. Multivariable analysis showed a significantly lower risk of repeat revascularization with DES use when compared with the use of BA (hazard ratio [HR] 0.41 [95% CI 0.29-0.58]) and BMS (HR 0.55 [95% CI 0.39-0.76]). After further adjustment for discharge medications, the lower risk for death/MI was not statistically significant for DES when compared with BA.

Conclusions: In patients with diabetes undergoing PCI, the use of DES is associated with a reduced need for repeat revascularization when compared with BA or BMS use. The associated death/MI benefit observed with the DES versus the BA group may well be due to greater use of pharmacotherapy.

Trial registration: ClinicalTrials.gov NCT00005677.

Figure 1

In-hospital outcomes (A) and discharge medication* use (B) after PCI by device type in patients with diabetes. *Percentages of antiplatelets and lipid-lowering drugs predominantly reflect information from the NHLBI-sponsored Dynamic Registry patients.

Figure 2

Cumulative (Kaplan-Meier) event rates for death/MI (A) and repeat revascularization (B) by device type at 1 year and 31–365 days after discharge.

Figure 3

Univariate and adjusted HRs (95% CI) for “late” (31–365 days) outcomes after percutaneous intervention by device type. *Adjusted for age, BMI, prior CABG, prior MI, history of hypertension, history of hypercholesterolemia, cardiogenic shock, severe noncardiac disease, vessel disease (single/double/triple), mean number of significant lesions, circumstances of index PCI, primary reason for index PCI (stable angina, unstable angina/acute MI asymptomatic CAD/others) and †discharge use of aspirin, β-blockers, lipid-lowering medications, ACE inhibitors, or angiotensin receptor blockers; thienopyridines were included only in models comparing BMS and DES.