Percutaneous Coronary Intervention In Diabetic Patients
S. Chiu Wong MD, FACC Associate Professor of Medicine Weill Medical College of Cornell University Director, Cardiac Catheterization Laboratories The New York Presbyterian Hospital-Cornell Campus
The ACC Symposium at the Great Wall Meeting, Beijing China
October 17, 2004
PCI in Diabetic Patients Summary
Prevalence of Diabetes Mellitus and its Associated Cost?
What are the Distinctive Features About Diabetic Vessels?
What is the Impact of Drug Eluting Stent in Diabetic Patients with CAD?
How could we Optimize PCI Treatment Strategies in Diabetic Patients?
PCI in Diabetic Patients
Prevalence of Diabetes Mellitus and its Associated Costs?
What are the Distinctive Features About Diabetic Vessels?
What is the Impact of Drug Eluting Stent in Diabetic Patients with CAD?
How Should we Optimize PCI Treatment Strategies in Diabetic Patients?
PCI in Diabetic Patients
Prevalence of Diabetes Mellitus and its Associated Costs?
What are the Distinctive Features About Diabetic Vessels?
What is the Impact of Drug Eluting Stent in Diabetic Patients with CAD?
How Should we Optimize PCI Treatment Strategies in Diabetic Patients?
Accessed on Oct 2, 2004. www.diabetes.org/diabetes-statistics/national-diabetes-fact-sheet.jsp
Source: National Diabetes Fact Sheet (American Diabetes Association)
National estimates on diabetes in the US in 2002
Total: 18.2 million people (6.3% of the population)
Approximately 90% of patients with diabetes have the type 2 variety which is associated with excess body fat and physical inactivity.
PCI in Diabetic Patients
Prevalence of DM Among US Adults
PCI in Diabetic Patients
Diabetes: A Genetic Legacy
Approximately 90% of patients with diabetes have the type 2 variety. The increasing prevalence of type 2 diabetes cannot be divorced from the rising incidence of obesity and physical inactivity in industrialized society. Both excess body fat and physical inactivity predispose to type 2 diabetes
Mokdad, A. H. et al. JAMA 2001;286:1195-1200.
PCI in Diabetic Patients
Prevalence of DM Among US Adults: 1990 vs. 2000
Incidence of a self-report of diagnosed diabetes increased from 4.9% in 1990 to 7.3% (49% increase) in 2000.
Saydah, S. H. et al. JAMA 2004;291:335-342.
PCI in Diabetic Patients
Percentages of Adults With Recommended Levels of Vascular Disease Risk Factors in NHANES III (1988-1994) and NHANES 1999-2000
PCI in Diabetic Patients Levels of HbA1c, blood pressure, and total cholesterol in NHANES Pts
Saydah SH et al. JAMA 2004; 291:335-342.
Estimated numbers of people with diabetes by region for 2000 and 2030 and summary of population changes
* A positive value indicates an increase, a negative value indicates a decrease.
Wild et al Diabetes Care 2004; 27:1047-53
PCI in Diabetic Patients
Countries with the highest # of estimated cases of DM for 2000 and 2030
“…..estimate that there would be 754 thousand new diabetics per year in 25-74 years old Chinese if the total population were 1.3 billion in China in the 21st century”
Hu YH, Li GW, Pan XR , Zhonghua Nei Ke Za Zhi. 1993 Mar;32(3):173-5.
PCI in Patients with Diabetes Mellitus Scope of the Problem
PCI in Diabetic Patients
Diabetes and Cardiovascular Complications
UKPDS Investigators Lancet 1998;352:837
Khaw KT et al. Ann Intern Med 2004; 141:413-420.
PCI in Diabetic Patients
EPIC-Norflk Study: Hemoglobin A1c and Mortality
Increase in all-cause mortality associated with 1 % increase in hemoglobin A1c by gender
Heart disease is the leading cause of diabetes-related deaths. Adults with diabetes have CV death rates ~2 to 4 times higher than adults non-diabetics.
About 65% of deaths among people with diabetes are due to heart disease and stroke.
PCI in Diabetic Patients
Complications of Diabetes in US: Heart Disease and Stroke
Accessed on Oct 2, 2004. www.diabetes.org/diabetes-statistics
Source: National Diabetes Fact Sheet (American Diabetes Association)
Haffner, S. M. et al. N Engl J Med 1998;339:229-234
In 1059 Type 2 Diabetic and 1378 Nondiabetic patients with and without Prior MI
PCI in Diabetic Patients Kaplan-Meier Estimates of the Probability of Death from CAD
Patients with diabetes have the same risk of death as non-diabetic patients who have had an previous MI
PCI in Patients with Diabetes Mellitus Scope of the Problem
PCI in Patients with Diabetes Mellitus Scope of the Problem
The total annual economic cost of diabetes in 2002 was estimated to be $132 billion, or one out of every 10 health care dollars spent in the US.
PCI in Diabetic Patients Health Care Cost of the Diabetes Mellitus in US
Differences in the Diabetic Artery: Insights from Angiography and IVUS
PCI in Diabetic Patients
Prevalence of Diabetes Mellitus and its Associated Costs?
What are the Distinctive Features About Diabetic Vessels?
What is the Impact of Drug Eluting Stent in Diabetic Patients with CAD?
How Should we Optimize Treatment Strategies Following PCI in Diabetic Patients?
Pajunen et al, Am J Cardiol 1997;80:550-556
Pajunen et al, Am J Cardiol 2000;86:1080-1085
p<0.0001
p<0.0001
p<0.0001
p=NS
p=NS
p=NS
Severity index=average of worst %DS in LM, LAD, LCX, and RCA
Extent index=% of cooronary segments involved in stenoses
Atheroma burden is based on sum of QCA plaque areas/sum of QCA segment lengths
PCI in Patients with Diabetes Mellitus Angiographic Findings in Diabetic Patients
Type I pts have More severe and more extensive disease
Type II DM pts have similar angiographic Findings as non-diabetics
Mechanisms of Restenosis Post PCI IVUS Findings
PCI in Patients with Diabetes Mellitus Pre-intervention IVUS Comparison of Diabetic vs Non-Diabetic Patients
Reference
Lesion
Reference plaque burden was higher in diabetics (51% vs 47%, p=0.0002)
Kornowski et al, Am J Cardiol 1998;81:1298-1304
p=0.02
p=0.04
PCI in Patients with Diabetes Mellitus Pre-intervention IVUS Assessment of Diabetic Patients According to Disease Duration
Reference
Lesion
52% of Diabetics >10yrs were insulin dependent compared to 19% of Diabetics <10yrs (p<0.0001)
p=0.02
p=0.1
p=0.02
p=0.003
p=0.004
PCI in Patients with Diabetes Mellitus Pre-intervention IVUS Comparison of Insulin-Treated vs Non-Insulin Treated Diabetics
Reference
Lesion
Insulin use was the only independent (and negative) predictor of reference segment EEM, and P&M CSA and lesion EEM and P&M CSA.
p=0.015
p<0.0001
p=0.0063
p<0.0001
Reference Segments
Mintz et al, J Am Coll Cardiol 1995;25:1479-85
Positive remodeling
Intermediate remodeling
Negative remodeling
Nishioka et al. J Am Coll Cardiol 1996; 27:1571-76
Lesions
PCI in Patients with Diabetes Mellitus Remodeling in Acute Coronary Syndromes
Schoenhagen et al. Circulation 2000;101:598-603
Remodeling
p<0.0001
PCI in Patients with Diabetes Mellitus Diabetes Modulates Remodeling in ACS and Stable Angina (n=927)
Abizaid, unpublished observations
Frequency of Positive Remodeling
PCI in Patients with Diabetes Mellitus Interaction of Diabetes,Vessel Size, Final MLD, and Multiple Stents on Restenosis Post-stenting
Elezi et al. J Am Coll Cardiol 1997;30:1428-36
Elezi et al. J Am Coll Cardiol 1998;32:1866-73
Probability& Predictors of Restenosis
PCI in Patients with Diabetes Mellitus IVUS findings in diabetic vs non-diabetic pts in non-stented lesions
WHC
p=NS
OARS
p=0.072
p=0.19
p=0.0392
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