Cardiovascular Business - January/February 2009 - (Page 16)

Patient ManageMent › By Justine Cadet Choosing the Best Path for the Diabetic Patient with Multivessel Disease the prevailing notion is that bypass surgery is superior to stenting in patients with diabetes. the truth, however, is more complicated, as the decisionmakers learn to examine the individual pathologies in lieu of standardization. Often, this process is more art than science in taking into account all of the parameters of a patient’s disease. Clinical support In the early 1990s, the NIH-funded BARI (Bypass Angioplasty Revascularization Investigation) trial was the first study to raise a concern about treating diabetics. The study found that diabetic patients with multivessel disease fared better with surgery than balloon angioplasty (see charts, above). At the time, bare-metal stents (BMS) and drug-eluting stents (DES) were not on the market. Williams points out, however, that there was a patient subset in the BARI registry, who declined randomization, but had the same eligibility. The surgeon and patient decided the treatment. Two-thirds of the patients chose angioplasty and the results were comparable to those who chose surgery, according to Williams. In the mid-1990s, Mehran and colleagues found that out of nearly 700 patients with multivessel disease, the diabetics did not do as well as the nondiabetics regarding stenting (BMS) versus coronary artery bypass graft (CABG) surgery (J Am Coll Cardiol 2004;43:1348-1355). Researchers from the JACC study also found that many insulin-dependent diabetics had more complications than those in the non-insulin-dependent group. “We know the vascular pathophysiology of atherosclerosis is a little different in patients with insulin-dependent diabetes. We find a lot more negative remodeling in them and their response to angioplasty might be very different from non-insulin-dependent diabetics. It’s very difficult to pinpoint why they are doing worse, but this patient population also has more diffused concomitant disease Stent vs. Graft: taxus, Boston scientific. Ge Healthcare’s innova x-ray cardiovascular lab imaging system. I n general, patients with diabetes are at a much higher risk for any kind of revascularization procedure because they have a lot of concomitant disease—both cardiovascular and extra-vascular. Whether undergoing stenting or bypass surgery, diabetic patients as a whole fare worse than nondiabetic patients. Roxana Mehran, MD, director of outcomes research, data coordination and analysis at the Center for Interventional Vascular Therapy at New York-Presbyterian Hospital/Columbia University Medical Center in New York City, suggests that controlling glycemia might produce better outcomes in diabetic patients who are on both oral agents and insulin. She adds that insulindependent diabetics tend to fare worse in stenting than those taking oral agents, which may simply result from the severity of the disease in the insulin-dependent population. David O. Williams, MD, chief of interventional cardiology at Rhode Island Hospital in Providence, however, suggests that specific lesion characteristics, more than insulin dependence, affect technical success of stenting diabetics. Williams concedes that some patients in this population should not be stented. “If it becomes a toss-up because of the patient’s anatomy, I would favor surgery. Clearly, there are diabetic patients with multivessel disease that can be treated appropriately with angioplasty—not all, but some,” he notes. 16 Cardiovascular Business January/February 2009

Table of Contents Feed for the Digital Edition of Cardiovascular Business - January/February 2009

Cardiovascular Business - January/February 2009 Contents First Word Electrophysiology Roundtable Forum: A Candid Conversation about Profits, Procedures and Patients Heart Failure Care Gets Boost from Technology Emerging Technologies in Peripheral Vascular Interventions Stent vs. Graft: Choosing the Best Path for the Diabetic Patient with Multivessel Disease Cardiology Groups and Hospitals Strive to ‘Connect’ Seamlessly CT Beyond 64 Slices Clinical Study Digest: Kidney Disease & PCI; Women and Valve Disease Compact Echo Systems Come Up Big in Cardiac Care News & Views Reader Resources The ACC Corner

Cardiovascular Business - January/February 2009

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