Metabolomics of repetitive myocardial stunning in chronic multivessel coronary artery stenosis: Effect of non-selective and selective ß1-receptor blockers.

Chronic coronary artery stenosis can lead to regional myocardial dysfunction in the absence of myocardial infarction by repetitive stunning, hibernation or both. The molecular mechanisms underlying repetitive stunning-associated myocardial dysfunction are not clear. We used non-targeted metabolomics to elucidate responses to chronically stunned myocardium in a canine model with and without ß-adrenergic blockade treatment. After development of left ventricular systolic dysfunction induced by ameroid constrictors on the coronary arteries, animals were randomized to 3 months of placebo, metoprolol or carvedilol. We compared these two ß-blockers with their different ß-adrenergic selectivities on myocardial function, perfusion and metabolic pathways involved in tissue undergoing chronic stunning. Control animals underwent sham surgery. Dysfunction in stunned myocardium was associated with reduced fatty acid oxidation and enhanced ketogenic amino acid metabolism, together with alterations in mitochondrial membrane phospholipid composition. These changes were consistent with impaired mitochondrial function and were linked to reduced nitric oxide and peroxisome proliferator-activated receptor signalling, resulting in a decline in adenosine monophosphate-activated protein kinase. Mitochondrial changes were ameliorated by carvedilol more than metoprolol, and improvement was linked to nitric oxide and possibly hydrogen sulphide signalling. In summary, repetitive myocardial stunning commonly seen in chronic multivessel coronary artery disease is associated with adverse metabolic remodelling linked to mitochondrial dysfunction and specific signalling pathways. These changes are reversed by ß-blockers, with the non-selective inhibitor having a more favourable impact. This is the first investigation to demonstrate that ß-blockade-associated improvement of ventricular function in chronic myocardial stunning is associated with restoration of mitochondrial function. KEY POINTS: The mechanisms responsible for the metabolic changes associated with repetitive myocardial stunning seen in chronic multivessel coronary artery disease have not been fully investigated. In a canine model of repetitive myocardial stunning, we showed that carvedilol, a non-selective ß-receptor blocker, ameliorated adverse metabolic remodelling compared to metoprolol, a selective ß1-receptor blocker, by improving nitric oxide synthase and adenosine monophosphate protein kinase function, enhancing calcium/calmodulin-dependent protein kinase, probably increasing hydrogen sulphide, and suppressing cyclic-adenosine monophosphate signalling. Mitochondrial fatty acid oxidation alterations were ameliorated by carvedilol to a larger extent than metoprolol; this improvement was linked to nitric oxide and possibly hydrogen sulphide signalling. Both ß-blockers improved the cardiac energy imbalance by reducing metabolites in ketogenic amino acid and nucleotide metabolism. These results elucidated why metabolic remodelling with carvedilol is preferable to metoprolol when treating chronic ischaemic left ventricular systolic dysfunction caused by repetitive myocardial stunning.

Safety and efficacy of the Low-Profile Visualized Intraluminal Support stent in treating intracranial atherosclerotic stenosis / Seguridad y efectividad del stent LVIS™ en el tratamiento de estenosis intracraneales ateroscleróticas

Purpose: The performance of the Low-Profile Visualized Intraluminal Support (LVIS) stentdeployed following balloon angioplasty is unknown in treating intracranial atherosclerotic stenosis, and this study was to investigate the safety and efficacy of the LVIS stent in treatingintracranial atherosclerotic stenosis in the middle cerebral artery M1 segment.Methods: Thirty-five patients were enrolled with 35 atherosclerotic stenoses at the M1 segment. The stenosis was about 75% in 16 patients, 80% in 15, and 90% in the rest four. The LVISstent was used to treat these patients. Results: The success rate of stenting was 97.1%. The stenting procedure was failed in onepatient because of intraprocedural dissection of the stenotic (75%) segment, resulting in a 30-day periprocedural complication rate of 2.9% (1/35). Before stenting, the stenosis rate ranged75%—90% (mean 78.9% ± 4.7%), and after stenting, the diameter of the stented segment wassignificantly (P < 0.0001) increased to 1.5—3.4 mm (mean 2.1 ± 0.32 mm) ranging 68.2%—100%(mean 94.0% ± 5.8%) of the normal arterial diameter, with the residual stenosis ranging 0—31.8%(median 4.8%, IQR 2.4%—7.3%). Follow-up was performed at 6—20 months (mean 8.5) afterstenting. One patient (2.9%) had occlusion of the stented M1 segment with no symptoms, andtwo patients (5.7%) had slight asymptomatic instent stenosis (40%) at the M1 segment, with theinstent restenosis and occlusion rate of 8.6% (3/35). Conclusion: The braided LVIS stent can be safely applied for treatment of intracranialatherosclerotic stenosis in the middle cerebral artery with good safety and efficacy immediatelyafter stenting and at follow-up.(AU)

Objetivo: Nos propusimos analizar la seguridad y efectividad de la colocación de un stentlow-profile visualized intraluminal support (LVIS TM ) tras angioplastia con balón en pacientescon estenosis ateroscleróticas intracraneales en el segmento M1 de la arteria cerebral media(ACM). Métodos: Incluimos 35 pacientes con estenosis ateroscleróticas en el segmento M1 de la ACM;la estenosis era del 75% en 16 pacientes, del 80% en 15 y del 90% en los 4 restantes. En todoslos casos el tratamiento se basó en la colocación de un stent LVIS TM . Resultados: El stent se implantó con éxito en el 97,1% de los casos; en un paciente, el procedimiento no se pudo llevar a cabo a causa de una disección del segmento estenótico (estenosisdel 75%) durante la operación, lo que supone una tasa de complicaciones perioperatorias a los30 días del 2,9%. Antes de la colocación del stent, el grado de estenosis oscilaba entre el 75 yel 90% (media [DS]: 78,9% [4,7%]). Tras el procedimiento, el diámetro del segmento en el quese había colocado el stent aumentó de forma significativa (P < 0,0001) hasta los 1,5-3,4 mm(media: 2,1 mm [0,32]), logrando un 68,2-100% (media: 94,0% [5,8%]) del diámetro normal dela arteria, y una estenosis residual del 0 al 31,8% (mediana: 4,8%; p25-p75, 2,4-7,3%). Se realizóun seguimiento de entre 6 y 20 meses (media: 8,5) tras el procedimiento. Un paciente (2,9%)presentó una oclusión asintomática del segmento M1 intervenido, y 2 pacientes (5,7%) presentaron estenosis intrastent asintomáticas leves (40%) en M1, por lo que la tasa de reestenosisintrastent y oclusión fue del 8,6%. Conclusión: El stent LVIS TM es un tratamiento seguro y efectivo para las estenosis ateroscleróticas intracraneales en la ACM.(AU)

Utilidad de la tomografía de coherencia óptica como guía en el tratamiento del síndrome coronario agudo: reporte de un caso / Utility of optical coherence tomography to guide treatment in acute coronary syndromes: case report / Utilidade da tomografia de coerência óptica como guia no tratamento da síndrome coronariana aguda: relato de um caso

La tomografía de coherencia óptica (OCT) es una técnica de imagen endovascular con elevada resolución espacial que permite evaluar las diferentes estructuras que componen la pared de las arterias coronarias, caracterizar morfológicamente la placa aterosclerótica y establecer el mecanismo fisiopatológico subyacente en los síndromes coronarios agudos (SCA). Se presenta el caso clínico de un paciente con infarto agudo de miocardio, donde la OCT evidenció que la reducción de la luz arterial estaba determinada principalmente por la presencia de trombo, a la vez que demostró una disrupción endotelial (ruptura de placa) como mecanismo fisiopatológico subyacente. Se adoptó una estrategia invasivo-conservadora, donde finalmente no se implantó stent. La información surgida de la OCT en este caso particular fue fundamental en la toma de decisiones.

Optical coherence tomography (OCT) is an endovascular imaging technique with high spatial resolution. It allows to evaluate the different structures that compose coronary arteries' wall, morphologically characterize atherosclerotic plaques and establish the underlying pathophysiological mechanism in acute coronary syndromes (ACS). The case of a patient with acute myocardial infarction is presented, in which OCT showed that the reduction of arterial lumen was determined mainly by the presence of thrombus, while also demonstrated endothelial disruption (plaque rupture) as the underlying pathophysiological mechanism. An invasive-conservative strategy was adopted and finally stent was not implanted. The information that emerged from the OCT in this particular case was fundamental in decision-making.

A tomografia de coerência óptica (OCT) é uma técnica de imagem endovascular com alta resolução espacial que permite a avaliação das diferentes estruturas que compõem a parede das artérias coronárias, a caracterização morfológica da placa aterosclerótica e o estabelecimento do mecanismo fisiopatológico subjacente de síndrome coronariana aguda (SCA). Apresentamos o caso clínico de um paciente com enfarte agudo do miocárdio, onde a OCT mostrou que a redução do lúmen arterial foi determinada principalmente pela presença de trombo, ao mesmo tempo que demonstrou uma ruptura endotelial (ruptura da placa) como causa fisiopatológica subjacente. Adotou-se uma estratégia invasiva-conservadora, onde finalmente o stent não foi implantado. As informações obtidas da OCT neste caso específico foram fundamentais na tomada de decisão.

Type 2 myocardial infarction resulted from the left thoracic stomach

Abstract The universal definition of myocardial infarction (MI) provides five subtypes of acute myocardial infarction (AMI). We present an interesting case of a type 2 myocardial infarction caused by the dilation of the left thoracic stomach.

Resultados a muy largo plazo tras la implantación de stents liberadores de fármacos en la estenosis de arteria coronaria principal izquierda no protegida: experiencia de un centro / Very long-term outcomes following drug-eluting stent implantation for unprotected left main coronary artery stenosis: a single center experience

Introducción y objetivos. Se han descrito resultados alentadores en el seguimiento a largo plazo de registros no aleatorizados y de ensayos aleatorizados tras la intervención coronaria percutánea con implantación de stents liberadores de fármacos para el tratamiento de la estenosis de la coronaria principal izquierda no protegida. Sin embargo, la información sobre los resultados a muy largo plazo (> 5 años) es limitada. El objetivo de este estudio es determinar los resultados a muy largo plazo (6 años) tras la implantación de stents liberadores de fármacos en la enfermedad coronaria de la principal izquierda. Métodos. Se analizaron los resultados de todos los pacientes consecutivos con estenosis de la coronaria principal izquierda no protegida que se trató de manera electiva con la implantación de stents liberadores de fármacos entre marzo de 2002 y mayo de 2005, según la localización de la lesión de la coronaria principal izquierda (bifurcación distal frente a ostium/cuerpo). Resultados. Se incluyó en el estudio a 149 pacientes: 113 con una lesión de la bifurcación distal y 36 con una lesión en ostium/cuerpo. La presencia de enfermedad de tres vasos fue significativamente mayor en el grupo de lesión distal que en el grupo de lesión en ostium/cuerpo (el 52,2 frente al 33,2%; p = 0,05). A los 6 años de seguimiento, la tasa acumulada de eventos cardiacos adversos mayores fue del 41,6% (el 45,1 distal frente al 30,6% en ostium/cuerpo; p = 0,1), incluidos el 18,8% de muerte de cualquier tipo (el 22,1 distal frente al 8,3% en ostium/cuerpo; p = 0,08), el 3,4% de infarto de miocardio (el 3,5 distal frente al 2,8% en ostium/cuerpo; p = 1) y el 15,4% de revascularización de lesión diana (el 18,6 distal frente al 5,6% en ostium/cuerpo; p = 0,06). La variable combinada de muerte cardiaca e infarto de miocardio se produjo en el 10,7% de los casos (el 13,3 distal frente al 2,8% en ostium/cuerpo; p = 0,1), mientras que la tasa de trombosis definitiva/probable del stent fue del 1,4% (todos en el grupo distal). Conclusiones. En un seguimiento clínico de 6 años, la intervención coronaria percutánea con implantación de stents liberadores de fármacos para lesiones de la coronaria principal izquierda no protegida se asoció a unas tasas aceptables de muerte cardiaca, infarto de miocardio y trombosis de stent. Se confirmaron los resultados a largo plazo favorables en las lesiones de ostium/cuerpo en comparación con las lesiones de la bifurcación distal en el seguimiento clínico a largo plazo(AU)

Introduction and objectives. Encouraging results at long-term follow-up have been reported from non-randomized registries and randomized trials following percutaneous coronary intervention with drug-eluting stent implantation for unprotected left main stenosis. However, information on very long-term (>5-year) outcomes is limited. The aim of this study was to assess the very long-term outcomes (6-years) following drug-eluting stent implantation for left main disease. Methods. All consecutive patients with unprotected left main stenosis electively treated with drug-eluting stent implantation, between March 2002 and May 2005, were analyzed according to the location of the left main lesion (distal bifurcation vs ostial/body). Results. The study included 149 patients: 113 with distal bifurcation and 36 with ostial/body lesion. Triple-vessel disease was significantly higher in the distal than in the ostial/body group (52.2% vs 33.2%, P=.05). At 6-years of follow-up, the cumulative major adverse cardiovascular event rate was 41.6% (45.1% distal vs 30.6% ostial/body, P=0.1), including 18.8% any death (22.1% distal vs 8.3% ostial/body, P=.08), 3.4% myocardial infarction (3.5% distal vs 2.8% ostial/body, P=1), and 15.4% target lesion revascularization (18.6% distal vs 5.6% ostial/body, P=.06). The composite of cardiac death and myocardial infarction was 10.7% (13.3% distal vs 2.8% ostial/body, P=.1) while the definite/probable stent thrombosis rate was 1.4% (all in the distal group). Conclusions. At 6-year clinical follow-up, percutaneous coronary intervention with drug-eluting stent implantation for unprotected left main disease was associated with acceptable rates of cardiac death, myocardial infarction and stent thrombosis. Favorable long-term outcomes in ostial/body lesions compared to distal bifurcation lesions were confirmed at long-term clinical follow-up(AU)

Acute and Long-Term Angiographic Outcomes of Side Branch Stenosis after Randomized Treatment of Zotarolimus-, Sirolimus-, and Paclitaxel-Eluting Stent for Coronary Artery Stenosis

This was designed to assess the outcomes of side branch (SB) stenosis after implantation of three drug-eluting stents (DES). From 2,645 patients in the ZEST (Comparison of the Efficacy and Safety of Zotarolimus-Eluting Stent with Sirolimus-Eluting and PacliTaxel-Eluting Stent for Coronary Lesions) Trial, 788 patients had 923 bifurcation lesions with SB > or = 1.5 mm were included. SB was treated in 150 lesions, including 35 (3.8%) receiving SB stenting. Of untreated SB with baseline stenosis < 50%, the incidences of periprocedural SB compromise was similar in the zotarolimus (15.8%), sirolimus (17.2%), and paclitaxel (16.6%) stent groups (P = 0.92). At follow-up angiography, delayed SB compromise occurred in 13.9%, 3.2%, and 9.4% (P = 0.010) of these groups. When classified into four groups (< 50%, 50%-70%, 70%-99%, and 100%), 9.0% of untreated SB were worsened, whereas improvement and stationary were observed in 9.6% and 81.4%. In a multivariable logistic regression model, main branch (MB) stenosis at follow-up (%) was the only independent predictor of SB stenosis worsening (odds ratio, 1.03; 95% confidence interval, 1.01-1.04; P < 0.001). After MB stenting in bifurcation lesions, a minority of SB appears to worsen. DES with strong anti-restenotic efficacy may help maintain SB patency.

Estudio ultrasónico de prevalencia de placa en la carina en lesiones que afectan a una bifurcación coronaria. Implicaciones en el tratamiento con stent provisional / Ultrasound study of the prevalence of plaque at the carina in lesions that affect the coronary bifurcation. Implications for treatment with provisional stent

Introducción y objetivos. Los patrones de distribución de placa en las lesiones en bifurcación coronaria son poco conocidos, y se ha especulado que la carina es inmune a la arteriosclerosis, debido al efecto ateroprotector derivado del high wall shear stress. El objetivo fue analizar con ecografía intracoronaria (EIC) la distribución de placa en lesiones en bifurcación coronaria y su prevalencia en la carina. Métodos. En 195 bifurcaciones coronarias, se hizo una EIC sobre el vaso principal (VP), y en 91 también sobre el ramo secundario (RS). Se consideró que había placa en la carina cuando el grosor era ≥ 0,3mm. Se midió la carga de placa en distintos puntos: referencia proximal, carina, punto de área luminal mínima (ALM) y referencia distal. Tras implantar el stent en el VP se realizó una EIC. Resultados. La prevalencia de placa en la carina fue del 32% y su grosor, 0,8±0,36mm, menor que el observado en la contracarina (1,22±0,54mm; p<0,01). La prevalencia de placa fue mayor (52%) cuando el punto de ALM estaba localizado distal a la carina. La presencia de placa en la carina se asoció a menor incidencia de daño del ostium del RS tras tratar el VP (el 32 frente al 54%; p=0,04). Conclusiones. La carina no es inmune a la arteriosclerosis y hay placa en un tercio de las bifurcaciones. La prevalencia de placa es mayor en bifurcaciones con ALM distal a la carina y parece asociarse a menor incidencia de daño del ostium del RS (AU)

Introduction and objectives: The plaque distribution patterns in coronary bifurcation lesions are not well understood. It has been speculated that carina is free of plaque partly because of high wall shear stress providing an atheroprotective effect. To study plaque distribution with intravascular ultrasound (IVUS) in the coronary bifurcation and the prevalence of carina involvement. Methods: IVUS study was performed on 195 coronary bifurcation lesions in the main vessel (MV) and on 91 in the side branch (SB). Plaque at the carina was considered when its thickness was > 0.3 mm. Plaque burden was measured at different levels: proximal reference, distal, carina and at the point of minimal lumen area (MLA). Results: The prevalence of plaque at the carina was 32%. Its thickness was 0.8 (0.36) mm, less than that observed at the counter-carina [1.22 (0.54) mm; P < .01]. The prevalence was higher (52%) when the MLA point was distal to the carina. The plaque at the carina was associated with a lower incidence of damage at the SB ostium after stenting the MV (32% vs 54%; P < .04). Conclusions: The carina is not immune to atherosclerosis, showing plaque at this level in one third of the bifurcations. The incidence of plaque is higher in those bifurcations with the MLA point distal to the carina and seems to be associated with a lower incidence of damage to the SB ostium (AU)

Análisis comparativo de las características clínico-angiográficasy de los resultados inmediatos y tardíos de stents liberadores de drogas vs. no liberadores / Immediate and late clinical an angiographic results of coronary stent implantation: comparison of drug eluting versus bare metal stents

Introducción: La reducción de la reestenosis intrastent ha permitido una gran aceptación de los stents liberadores de drogas (DES). El objetivo de este trabajo ha sido evaluar nuestra experiencia clínica inicial con DES y compararla con aquellos que sólo recibieron BMS (stents no liberadores de drogas). Materiales y Métodos: Se compararon 71 pacientes tratados con DES (Cypher® = 32 o Taxus® = 39) con 903 pacientes tratados sólo con BMS. Además del análisis clínico y angiográfico detallado, se efectuó seguimiento clínico de a lo menos 6 meses. Resultados: Los pacientes tratados con DES con mayor frecuencia eran más complejos y tenían características clínicas y angiográficas desfavorables. Sin embargo, no hubo diferencias en la tasa de éxito angiográfico (100 vs. 99,2 por ciento) ni en las complicaciones isquémicas intrahospitalarias (1,3 vs. 0 por ciento). En el seguimiento los tratados con DES tuvieron menor recurrencia de la angina (8,7 vs. 19,0 por ciento), revascularización del vaso tratado (0 vs. 7,5 por ciento) y menos eventos isquémicos (4,4 por ciento vs. 14,6 por ciento). Conclusiones: A pesar de su empleo en pacientes con características clínicas y angiográficas desfavorables, los DES lograron un mejor resultado a largo plazo en comparación con los BMS.

Background: There has been considerable enthusiasm for drug eluting stents (DES) in coronary angioplasty due to the lower restenosis rate associated to their use. Aim: To compare clinical and angiographic results of DES implantation, compared to traditional bare metal stents (BMS) Methods: 71 patients who received DES (Cypher® = 32; Taxus® = 39) were compared to 903 patients who had received BMS. Detailed clinical and angiographic evaluation and 6 month follow up data were analyzed. T test and X2 analysis were used for comparisons. Results: Compared to the BMS group, the DES group had complex clinical (diabetes mellitus, family history, active smokers) and agiographic findings (lower ejection fraction, longer lesions) in a greater proportion of cases (p < 0.05 vs BMS). The immediate angiographic success rate did not differ between groups (100 percent vs 99.2 percent, respectively). Acute ischemic complications occurred in 1.3 percent in DES patients compared to 0 percent in BMS (pNS). At follow-up, angina recurrence (8.7 percent vs 19 percent, p < 0.043), need for revascularization (0 percent vs 7.5 percent, p < 0.02) and new ischemic events (4.4 percent vs 14.6 percent, p < 0.02) were lower in DES as compared to BMS patients. Conclusion: In spite of the greater clinical and angiographic complexity, patients with DES had better long term clinical results than patients who received BMS.

Análise comparativa da hiperplasia intimal após o implante de stents com e sem sirolimus em artérias coronárias de pequeno calibre / Comparative analysis of intimal hyperplasia after sirolimus-eluting stent and thin-strut bare-metal stent implantation in small coronary arteries

OBJETIVO: Avaliar a redução do volume de hiperplasia intimal após angioplastia com stents com sirolimus (Cypher®) comparados com os stents não-recobertos de estrutura metálica fina (Pixel®) em pacientes com vasos pequenos. MÉTODOS: Oitenta pacientes com doença arterial coronariana foram prospectivamente incluídos em duas séries consecutivas de tratamento, sendo a primeira empregando stents com sirolimus (50) e a segunda stents não-recobertos de estrutura metálica fina (30). RESULTADOS: Os resultados foram: menor porcentual de obstrução da prótese através do ultra-som intracoronário [5,0 por cento (EP = 0,77) x 39,0 por cento (EP = 4,72), p < 0,001], menor perda tardia intra-stent [0,25 mm (EP = 0,03) x 1,11 mm (EP = 0,13), p < 0,001] e no segmento do vaso [0,30 mm (EP = 0,04) x 0,83 mm (EP = 0,11), p < 0,001], e também menor reestenose intra-stent (0 por cento x 33,3 por cento, p < 0,001) e no segmento do vaso (4 por cento x 36,7 por cento, p < 0,001) com os stents com sirolimus. A sobrevivência livre de eventos foi de 96 por cento com os stents com sirolimus x 86,7 por cento com os stents não-recobertos (p = 0,190). CONCLUSÃO: Os pacientes com vasos de pequeno calibre após o implante de stents com sirolimus evoluem com menor hiperplasia intimal (menor porcentual de obstrução intra-stent e menor perda tardia) do que quando são utilizados stents não-recobertos de estrutura metálica fina. Isto resultou em redução significativa da reestenose angiográfica aos oito meses de evolução.

Volumetric analysis of in-stent intimal hyperplasia in diabetic patients treated with or without abciximab: results of the Diabetes Abciximab STENT Evaluation (DANTE) randomized trial

Inhibitor for Stenting (EPISTENT) trial, abciximab educed target vessel revascularization by approximately 50% compared with placebo. Whether this is a result of a lower restenosis rate caused by inhibition of intimal hyperplasia remains to be defined. METHODS AND RESULTS: The purpose of this study was to determine whether abciximab at the time of stent implantation would reduce in-stent intimal hyperplasia measured by intravascular ultrasound at 6-month follow-up in type 2 diabetics. Ninety-six diabetic patients (96 lesions) who underwent elective stent implantation for a de novo lesion in a native coronary artery were randomly assigned to receive abciximab or no abciximab. In-stent intimal hyperplasia volume, expressed as percentage of stent volume, did not differ between groups: 41.3+/-21.0% for those treated with abciximab versus 40.5+/-18.3% for those treated without abciximab (P=0.9). There were also no significant differences in angiographic minimal luminal diameter at follow-up (1.74+/-0.69 versus 1.66+/-0.63 mm; P=0.5), late loss (1.03+/-0.63 versus 1.07+/-0.58 mm; P=0.7), restenosis rate (17.8% versus 22.9%; P=0.5), or cumulative incidence of major adverse cardiac events at 12 months (19.1% versus 20.4%; P=0.9). CONCLUSIONS: Six-month intravascular ultrasound volumetric analysis showed that abciximab, at the time of coronary stent implantation, was not associated with a reduction of in-stent intimal hyperplasia in diabetic patients...

Sirolimus-eluting stents inhibit neointimal hyperplasia in diabetic patients. Insights from the RAVEL Trial

Patients with diabetes mellitus have less favourable outcomes after percutaneous coronary intervention (PCI) than non-diabetics. We performed a subgroup analysis of the multicentre RAVEL trial to examine the impact of the sirolimus-eluting stent (SES) on outcomes in diabetic patients. The RAVEL study randomized 238 patients to treatment with either sirolimus-eluting or bare metal stents. Forty-four patients were diabetic; 19 received sirolimus-eluting stents and 25 were treated with bare metal stents. The differences in outcomes between diabetic and non-diabetic patients treated with SES (n=101) were also assessed. Follow-up angiography was performed at 6 months. Major adverse cardiac events (MACE) defined as death, myocardial infarction (MI), or target lesion revascularization (TLR) were analysed at 12-month follow-up. Six-month in-stent late lumen loss was significantly lower for the diabetic SES than the bare stent group (0.07+/-0.2 vs 0.82+/-0.5mm; P<0.001) and similar to that in non-diabetics treated with SES (-0.03+/-0.27mm). There was zero restenosis in the SES groups (diabetic and non-diabetic) compared to a 42%r ate in the diabetic population assigned to bare metal stents (P=0.001) After 12 months, there was one non-Q-wave MI and one non-cardiac death in the diabetic SES group, while 12 patients in the bare metal stent group had MACE (one death, two MI, nine TLR) (P=0.01)-an event-free survival rate of 90% vs 52%, respectively (P<0.01). There were no TLRs in both SES groups compared to 36% rate in the diabetic bare metal stent group (P=0.007)...