Percutaneous coronary intervention in patients with diabetes: current concepts and future directions

Abstract

Patients with diabetes and coronary artery disease represent a challenging and growing subset of the population. Although surgical revascularization is the preferred treatment for patients with diabetes and multivessel coronary artery disease with stable angina, a significant proportion of diabetic patients undergo percutaneous revascularization due to comorbidities, presence of single-vessel disease, or presentation with myocardial infarction. The development of drug-eluting stents has significantly improved the results of percutaneous revascularization among diabetic patients, but a number of challenges remain, including higher rates of restenosis and stent thrombosis among diabetic patients. With current technologies, the outcomes of diabetic patients treated with noninsulin agents have approached that of nondiabetic patients. In comparison, patients with diabetes who require insulin therapy represent a high-risk cohort with increased rates of target vessel failure after coronary revascularization. The development of bioresorbable stents and new drug elution systems may provide additional future benefit among patients with diabetes undergoing percutaneous coronary artery revascularization.

Keywords: coronary artery disease; diabetes; drug-eluting stents.

Figure 1.

Differential outcomes after percutaneous coronary intervention (PCI) among patients with and without diabetes treated with everolimus-eluting or paclitaxel-eluting stents. (A) Among patients without diabetes, the rates of major adverse cardiovascular events were significantly lower for those treated with everolimus-eluting stents (EES) compared to paclitaxel-eluting stents (PES). However, patients with DM had similar outcomes regardless of the drug-eluting stent type. (B) Among patients without diabetes, EES were also associated with significantly decreased rates of target lesion revascularization (TLR). In comparison, there was no relationship between stent type and TLR among patients with DM. (Reproduced, with permission, from Stone et al.)

Figure 2.

Association of insulin-treated diabetes with outcomes after percutaneous coronary intervention with Resolute zotarolimus-eluting stents (R-ZES). Patient-level data were pooled from 5130 patients receiving R-ZES in 5 clinical trials (Resolute FIM, Resolute All Comers, Resolute International, Resolute US and Resolute Japan). Patients without diabetes (non-DM) and those with diabetes treated with agents other than insulin (non-ITDM) had similar rates of target lesion failure (TLF; defined as a composite of cardiac death, target vessel myocardial infarction, and ischemia-driven target vessel revascularization). Patients with diabetes who required treatment with insulin (ITDM) had significantly increased rates of adverse events. (Reproduced, with permission, from Silber et al.)