Slide 1

Nei diabetici con cardiopatia ischemica la rivascolarizzazione con CABG sempre superiore? Prof. F. Romeo University of RomeTor Vergata Department of Cardiology Slide 2 Atherosclerosis in Diabetes Mellitus: Pathophysiologic Considerations Abnormal platelet function activation and adhesion in response to shear stress expression of GpIIb/IIIa receptors aggregation More diffuse atherosclerosis pattern Impaired coronary flow reserve reduced tolerance of embolization plaque burden and more lipid-rich plaques predisposed to rupture Impaired ability to develop collaterals larger MIs Increased response to vascular injury rates of restenosis and reocclusion following both balloon angioplasty and bare stent implantation Slide 3 Diabetes TLR expression patterns can induce distinct types of vascular inflammation as result of selective susceptibility of different regions of the vascular tree to atherosclerosis It has been shown that Apolipoprotein A-I, the major protein component of serum high-density lipoproteins, inhibits DC differentiation and maturation PPAR-a agonists ciglitazone and fenofibrate also inhibit oxLDL-induced maturation and immune functions of DCs in vitro Advanced glycosylation end products can promote atherosclerosis by inducing maturation of Slide 4 Patients with diabetes mellitus Increased incidence of CAD More extensive disease at angiography Worse prognosis than non-diabetic CAD >20% of all revascularisation procedures Slide 5 Revascularisation in Diabetes Mellitus Heartwire (www.theheart.org) Nov 1999 Despite stents, diabetic patients undergoing PCI still face higher death rates. AHA Scientific Statement 1999 Recent studies indicate that coronary angioplasty is less efficacious for patients with diabetes than for those without; these reports further reveal that CABG is the preferred therapy in patients with diabetes when invasive management is required. Slide 6 The 1991 Guidelines for CABG state that : the evidence is complete that the coronary artery bypass operation relieves angina in most patients. Some caution must be expressed in the use of CABG for relief of symptoms. CABG treats the manifestations of CAD, not the disease of process. The second important recommendation for CABG, after relief of symptoms, is prolongation of life. Slide 7 The explosive growth of PCI in the last decade mandates a careful examination of CABG survival versus PCI survival Slide 8 BARI: Impact of Diabetes on Survival NEJM 1996;335:217-25 CABG PTCA BARI Subgroups Treated diabetic pts only subgroup to show significant survival advantage with CABG 5 year survival CABG 81% PTCA 65% Diabetic subgroup (p=0.006) balloon angioplasty era 5 year survival Slide 9 PCI v CABG Trials - DM Subgroup Analyses ARTS trial - stent era 1205 patients - DM 208 (17%) CABG PCI 1 year mortality 3.1% 6.3% 1 year repeat revasc 12.4% 21.6% 3 year event free 81.3% 52.7% Slide 10 Do Diabetics Have Increased Mortality After Multivessel Stenting? * P