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Diabetes increased long-term CV events in older PCI-treated patients
Diabetes, particularly when treated with insulin, was independently and strongly associated with increased long-term adverse events in older patients who had undergone drug-eluting and bare-metal stent implantation.
Researchers of the study, published in the Journal of the American College of Cardiology, characterized long-term outcomes of PCI in patients with diabetes aged older than 65 years in routine practice by examining data from 405,679 patients aged older than 65 years who underwent PCI from 2004 to 2008 at 946 US hospitals. Data were linked to Medicare inpatient claims data. Overall, 33% of the patients had diabetes, of whom 9.8% were treated with insulin and 23.3% were not treated with insulin.
During a median of 18.4 months of follow-up, there was a significantly increased risk for death among insulin- (HR=1.91; 95% CI, 1.86-1.96) and noninsulin-treated (HR=1.32; 95% CI, 1.29-1.35) patients with diabetes compared with nondiabetic patients.
There was also more MI for insulin- (HR=1.87; 95% CI, 1.79-1.95) and noninsulin-treated (HR=1.29; 95% CI, 1.25-1.34) patients with diabetes compared with nondiabetic patients. The adjusted hazards were also significantly increased for those undergoing additional revascularization procedures (HR for insulin-treated patients=1.14; 95% CI, 1.10-1.18; HR for noninsulin-treated patients=1.08; 95% CI, 1.05-1.10) and subsequent hospitalization for bleeding (HR for insulin-treated patients=1.40; 95% CI, 1.31-1.50; HR for noninsulin-treated patients=1.18; 95% CI, 1.13-1.24).
“The mechanisms for this incremental risk of adverse CV events in older diabetic patients compared with nondiabetic patients, particularly for death and MI after PCI with both DES and BMS, is likely multifactorial,” researchers wrote. “Hypotheses include a greater underlying burden of atherosclerosis, microvascular disease, a prothrombotic state, more neointimal hyperplasia, greater vascular inflammation and/or further accumulation of diabetes-related end-organ damage and comorbidities during the 30- to 50-month follow-up period.”
Disclosure: Hillegass reports no relevant financial disclosures.
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This study did not address whether PCI was effective in diabetes but rather that diabetes is an independent predictor of outcome in elderly patients undergoing PCI. It also showed that insulin-dependent diabetics have a worse outcome that non-insulin-dependent diabetics.
The findings confirm a large body of data supporting this finding. The new observation was that not only does DES use, compared with BMS use, result in a reduction in repeat revascularization as would be expected, but that it reduces death and MI even after adjustment.
I think this makes a compelling case for the use of DES in diabetics.