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‘Silent’ diabetes associated with increased event risk after PCI
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Undetected diabetes and prediabetes were found in about one-third of patients undergoing PCI, and this “silent” diabetes was linked to a significantly increased risk for worse outcomes after the procedure, according to data from the BIO-RESORT Silent Diabetes study.
In the randomized, multicenter BIO-RESORT trial, patients undergoing PCI were treated with an everolimus-eluting stent (Synergy, Boston Scientific), a sirolimus-eluting stent (Orsiro, Biotronik) or a zotarolimus-eluting stent (Resolute Integrity, Medtronic).
In this predefined substudy, participants in BIO-RESORT who did not have known diabetes and were treated at Thoraxcentrum Twente in the Netherlands underwent oral glucose tolerance testing (OGTT) and assessment of HbA1c with fasting plasma glucose. The primary endpoint was target vessel failure, defined as a composite of death, target-vessel MI or target vessel revascularization, at 1 year.
Of 988 patients included in the substudy, 33.4% had abnormal glucose metabolism based on OGTT or HbA1c and fasting plasma glucose levels. Of these patients, 7.2% had silent diabetes. At 1 year, more patients with abnormal glucose metabolism, as compared with normal glucose metabolism, experienced the primary endpoint (6.4% vs. 2.7%; P = .006).
“In other words, more than half (54%) of the target vessel failures occurred in the one-third of study participants who had abnormal glucose metabolism; specifically, silent diabetic patients comprised 7% of the study participants and accounted for 23% of all target vessel failures,” the researchers wrote.
Based on OGTT only, silent diabetes was detected in 6.9% of patients, prediabetes in 13.4% and normal glucose tolerance in 79.8%. The rate of the primary endpoint was higher in patients with silent diabetes (13.2%), as compared with those with prediabetes (7.6%) and normal glucose tolerance (4.8%; P < .001). The risk for the primary endpoint was also higher among patients with silent diabetes vs. normal glucose tolerance (HR = 4.2; 95% CI, 1.93-9.21), according to the data.
Based on HbA1c and fasting plasma glucose, silent diabetes was detected in 3.3% of patients, prediabetes in 22% and normal glucose metabolism in 74.7%. Again, the primary endpoint occurred more often in patients with silent diabetes (12.1% vs. 5.5% for prediabetes and 3.1% for normal glucose metabolism; P = .01) and risk for the primary endpoint was about threefold higher than in patients with normal glucose metabolism (HR = 3.31; 95% CI, 1.13-9.7).
The differences in rates of the primary endpoint were primarily driven by a higher incidence of target-vessel MI in patients with silent diabetes (P < .001), which primarily occurred within 48 hours of the PCI procedure (P < .001).
Additionally, abnormal glucose metabolism, based on OGTT or HbA1c and fasting plasma glucose, independently predicted adverse event risk in multivariate analyses (HR = 2.2; 95% CI, 1.2-4.2).
“For interventional cardiologists, the role of screening for dysglycemia has been proposed as an important marker of outcomes after PCI but it is not a routine part of clinical guidelines,” Michael E. Farkouh, MD, from the Peter Munk Cardiac Centre, Heart and Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, University of Toronto, wrote in an accompanying editorial.
“It is refreshing to observe the interest of the interventional community to better characterize their patients and to provide more individualized care,” he wrote, highlighting the importance of identifying patients with silent diabetes or prediabetes early to prevent complications as well as the debate over which revascularization strategy is best for these patients.
“The guidelines for post-PCI patients must adopt these new metrics by routinely screening all PCI patients with a fasting plasma glucose level and a hemoglobin A1c,” he wrote. – by Melissa Foster
Disclosures: The study was supported by Biotronik, Boston Scientific and Medtronic. Thoraxcentrum Twente has received research grants from AstraZeneca, Biotronik, Boston Scientific and Medtronic. Please see the study for all the authors’ relevant financial disclosures. Farkouh reports no relevant financial disclosures.
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