Coronary artery disease
Predictors of In-stent Restenosis and Patient Outcome After Percutaneous Coronary Intervention in Patients With Diabetes Mellitus

https://doi.org/10.1016/j.amjcard.2007.03.097Get rights and content

Diabetics have a significantly higher incidence of major adverse cardiac events (MACEs) and in-stent restenosis (ISR) than nondiabetics after percutaneous coronary intervention (PCI). Predictors of MACEs and ISR are uncertain in diabetics. In recent studies, microalbuminuria and proliferative retinopathy have been believed to relate to progressive coronary atherosclerosis. We retrospectively studied 191 consecutive patients (mean age 65 ± 9 years) with diabetes who underwent PCI to determine predictors of ISR and MACEs (defined as cumulative incidence of myocardial infarction, revascularization, or death from cardiovascular cause), with special reference to microalbuminuria and proliferative retinopathy. Of 191 patients, 106 (56%) had a follow-up coronary angiogram at 16 ± 2 months. Of these 106 patients, 66 (62%) developed ISR. In the multivariate model, microalbuminuria or proliferative retinopathy did not achieve significant association with ISR. Serum high-density lipoprotein cholesterol levels were significantly associated with a lower incidence of ISR (odds ratio [OR] 0.928, 95% confidence interval [CI] 0.876 to 0.983, p = 0.011) and MACEs (OR 0.96, 95% CI 0.931 to 1.000, p = 0.048). Use of drug-eluting stents also had a negative association with ISR (OR 0.171, 95% CI 0.05 to 0.585, p = 0.004). Renal insufficiency was associated with higher MACEs (OR 3.19, 95% CI 1.45 to 7.031, p = 0.0039). In conclusion, serum high-density lipoprotein cholesterol levels were inversely associated with ISR or MACEs.

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Methods

We studied 191 consecutive patients with type 2 diabetes mellitus who underwent PCI with stent placement between January 2002 and December 2004. All patients were tested for microalbuminuria, and all patients had an eye examination for the presence of retinopathy. Patients with urine albumin levels <30 mg/g of creatinine were considered as having normal albuminuria, those with urine albumin levels of 30 to 300 mg/g of creatinine as having microalbuminuria, and those with albumin levels >300

Results

Table 1 lists demographics and baseline characteristics of the study population. Of the 191 patients, 50 (26%) had acute coronary syndrome and 141 (74%) had stable ischemic heart disease (exercise-induced angina pectoris, positive stress test result, arrhythmias, syncope with electrocardiographic changes, or symptomatic coronary artery disease on preoperative evaluation). Drug-eluting stents were used in 66 of 191 patients (34.5%). All patients received aspirin and clopidogrel after PCI.

Discussion

Although microalbuminuria is a marker for macrovascular and microvascular diseases in diabetics, diabetic retinopathy is a microvascular disease characterized by thickening of the retinal basement membrane, endothelial cell proliferation, and neovascularization. Some of these features are akin to intimal proliferation seen in ISR. Some follow-up studies have shown that diabetic retinopathy is associated with angiographically severe coronary artery disease and high cardiovascular mortality.6, 7,

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