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1.
J Am Coll Cardiol ; 36(2): 355-65, 2000 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-10933343

RESUMO

OBJECTIVES: The aim of this review is to discuss the particularities of coronary artery disease (CAD), the effect of intensive medical management and the outcome of percutaneous and surgical revascularization in patients with diabetes mellitus (DM). BACKGROUND: CAD represents the leading cause of death in patients with DM. Numerous clinical, biological and angiographic risk factors have been shown to be associated with CAD in diabetic patients. METHODS: Metabolic abnormalities in patients with DM including insulin resistance, hyperglycemia and dyslipidemia are briefly discussed. Then the potential roles of medical management and of percutaneous and surgical coronary revascularization are more extensively reviewed. RESULTS: More vigorous control of hyperglycemia, hyperlipidemia, hypertension and other risk factors may be of crucial importance for risk reduction. Despite remarkable progress in recent years, the choice of a coronary revascularization strategy remains a challenge in these patients. Diabetic patients with CAD are predisposed to higher cardiovascular events after balloon angioplasty. Whether stenting and new antiplatelet drugs improve the results of percutaneous revascularization in this population needs further evaluation. The superiority of the surgical approach is also not definitely established. Therefore, many aspects of coronary revascularization are still unclear in these patients. CONCLUSIONS: The results of ongoing randomized trials comparing multiple coronary stents to bypass surgery will likely provide some answers to our questions and additional randomized trials evaluating intensive diabetic control with or without coronary revascularization are needed to determine the best therapeutic approach in these patients.


Assuntos
Angiopatias Diabéticas/terapia , Abciximab , Angioplastia Coronária com Balão , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anticorpos Monoclonais/uso terapêutico , Anticoagulantes/uso terapêutico , Angiopatias Diabéticas/tratamento farmacológico , Angiopatias Diabéticas/metabolismo , Angiopatias Diabéticas/fisiopatologia , Endotélio Vascular/fisiopatologia , Humanos , Hiperglicemia/fisiopatologia , Hiperlipidemias/fisiopatologia , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Resistência à Insulina , Inibidores da Agregação Plaquetária/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Recidiva , Fatores de Risco , Terapia Trombolítica , Resultado do Tratamento
2.
Diabetes Care ; 22(1): 19-26, 1999 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-10333898

RESUMO

OBJECTIVE: We evaluated the prognostic value of an exercise stress test and thallium-201 scintigraphy for the prediction of cardiac events in selected high-risk NIDDM patients. RESEARCH DESIGN AND METHODS: NIDDM patients (n = 158, 105 men, aged 63 +/- 9 years) with two or more of the following criteria were prospectively included: age > or = 65 years, active smoking, hypertension > 160/95 mmHg, hypercholesterolemia (cholesterol > 5.70 mmol/l or LDL > 3.10 mmol/l), peripheral artery disease, abnormal rest electrocardiogram, or microalbuminuria (20-200 micrograms/min). An exercise-stress scintigraphy was performed in 77 patients able to exercise, while a dipyridamole scintigraphy was performed in 80 patients unable to exercise. Follow-up was 23 +/- 17 months. Major end points were cardiac deaths or nonfatal myocardial infarction. RESULTS: The annual event rate was 7.31% (deaths: 8, myocardial infarction: 14). Independent predictors of events were as follows: an age > 60 (P = 0.02), an abnormal rest electrocardiogram (P = 0.02), microalbuminuria (P = 0.001), the inability to exercise (P = 0.009), and the presence of more than two defects on scintigraphy (P = 0.001). A cardiac death occurred in 1.3% of patients able to exercise versus 8.8% of patients unable to exercise (odds ratio = 6.8, P = 0.001). Among patients unable to exercise, large perfusion defects corresponded to an annual mortality rate of 22.3%. Conversely, the negative predictive value of a normal scintigraphy for the occurrence of death was 97%. CONCLUSIONS: Inability to exercise and large perfusion defects on thallium-201 scan are major predictors of future death and myocardial infarction in high-risk NIDDM patients.


Assuntos
Doenças Cardiovasculares/epidemiologia , Morte Súbita Cardíaca/epidemiologia , Diabetes Mellitus Tipo 2/diagnóstico por imagem , Diabetes Mellitus Tipo 2/fisiopatologia , Teste de Esforço , Coração/diagnóstico por imagem , Infarto do Miocárdio/epidemiologia , Tomografia Computadorizada de Emissão de Fóton Único , Atividades Cotidianas , Idoso , Análise de Variância , Colesterol/sangue , HDL-Colesterol/sangue , Diabetes Mellitus Tipo 2/mortalidade , Angiopatias Diabéticas/epidemiologia , Angiopatias Diabéticas/fisiopatologia , Dipiridamol , Exercício Físico , Feminino , Coração/fisiopatologia , Humanos , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Valor Preditivo dos Testes , Prognóstico , Fatores de Risco , Radioisótopos de Tálio , Vasodilatadores
3.
Catheter Cardiovasc Interv ; 48(3): 304-7, 1999 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-10525235

RESUMO

Coronary rupture is a rare complication of percutaneous coronary intervention. However, it may be associated with serious hemodynamic consequences often leading to tamponade, myocardial infarction, emergency surgical intervention, or death. We report a successful percutaneous repair of a brisk left anterior descending coronary artery perforation by the implantation of a Magic Wallstent.


Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Implante de Prótese Vascular/instrumentação , Doença das Coronárias/cirurgia , Vasos Coronários/lesões , Stents , Angiografia Coronária , Doença das Coronárias/diagnóstico , Doença das Coronárias/etiologia , Vasos Coronários/cirurgia , Ecocardiografia , Humanos , Masculino , Pessoa de Meia-Idade , Ruptura/diagnóstico , Ruptura/etiologia , Ruptura/cirurgia
4.
Circulation ; 100(25): 2477-84, 1999.
Artigo em Inglês | MEDLINE | ID: mdl-10604884

RESUMO

BACKGROUND: Stenting likely decreases the need for target-vessel revascularization procedures in diabetic patients compared with balloon angioplasty. However, the efficacy of stenting with platelet glycoprotein IIb/IIIa blockade has not yet been assessed in diabetics. METHODS AND RESULTS: We analyzed the outcomes of 491 diabetic patients within the multicenter Evaluation of Platelet IIb/IIIa Inhibitor for Stenting Trial (EPISTENT). Diabetic patients were a prospectively defined subset: 173 were randomized to stent-placebo, 162 to stent-abciximab, and 156 to balloon angioplasty-abciximab. The main end point for this analysis was combined 6-month death, myocardial infarction (MI), or target-vessel revascularization (TVR). The composite end point occurred in 25.2% of stent-placebo, 23.4% of balloon-abciximab, and 13.0% of stent-abciximab patients (P=0.005). Abciximab therapy, irrespective of revascularization strategy (stent or balloon angioplasty), resulted in a significant reduction in the 6-month death or MI rate: 12.7% for stent-placebo, 7.8% for balloon angioplasty-abciximab, and 6.2% for the stent-abciximab group (P=0.029). The 6-month TVR rate was 16.6% for stent-placebo, 18.4% for balloon-abciximab, and 8.1% for stent-abciximab (P=0.021). Compared with stent-placebo, stent-abciximab therapy was associated with a significant increase in angiographic net gain (0.88 versus 0.55 mm; P=0.011) and a decrease in the late loss index (0.40 versus 0.60 mm; P=0.061). The 1-year mortality rate for diabetics was 4.1% for stent-placebo and 1. 2% for stent-abciximab patients (P=0.11). CONCLUSIONS: The combination of stenting and abciximab therapy among diabetics resulted in a significant reduction in 6-month rates of death, MI, and TVR compared with stent-placebo or balloon-abciximab therapy.


Assuntos
Angioplastia Coronária com Balão , Anticorpos Monoclonais/uso terapêutico , Doença da Artéria Coronariana/terapia , Complicações do Diabetes , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Revascularização Miocárdica , Inibidores da Agregação Plaquetária/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Stents , Abciximab , Idoso , Estudos de Coortes , Terapia Combinada , Angiografia Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Resistência à Insulina , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/prevenção & controle , Obesidade/complicações , Estudos Prospectivos , Recidiva , Fatores de Risco , Método Simples-Cego , Taxa de Sobrevida , Resultado do Tratamento
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