Original Title: Impact of diabetic status on outcomes after revascularization with drug-eluting stents in relation to coronary artery disease complexity. Reference: Koskinas KC et al. Circ Cardiovasc Intv. 2016; Epub ahead of print

Diabetic patients ongoing PCI with drug eluting stents (DES) are at higher risk of repeat revascularization than non-diabetic patients. According to this new analysis, the impact of diabetes on DES outcomes is not affected by SYNTAX score or the use of new generation DES.

These findings show that diabetes alone, and not disease complexity, justifies poor outcomes in these patients.

This study analyzed 4 large studies (SIRTAX, RESOLUTE All Comers, BIOSCIENCE and LEADERS) including a total of 6081 patients between 2004 and 2013. There were no restrictions in the number of lesions, treated vessels, lesion length or number of implanted stents. In all, 22% of patients had a history of diabetes and 75% received first generation DES.

Diabetic patients presented a higher median Syntax score (13.9 vs 12.9; P< 0.001) and received multivessel PCI more often (25% vs 22%; P =0.03) than the non-diabetic cohort.

After multivariable adjustment, the combined events rate (primary end point of cardiac death, non-fatal infarction and clinically indicated target vessel revascularization) was higher for the diabetic group (HR 1.25, CI 95% 1.03 to 1.53), as were vessel and lesion revascularization (HR 1.54, CI 95% 1.18 to 2.01 and HR 1.38, CI 95% 1.08 to 1.76 respectively).

However, events such as cardiac death, non-fatal infarction and stent thrombosis saw no differences between the groups.

All these data were no different when analyzing only patients receiving new generation DES (n=4554).

In multivariable analysis, there was no formal interaction as regards events in the group of diabetic patients stratified according to Syntax score. Assessing Syntax score as an ongoing variable to avoid the possible confounder, an arbitrary cut off, also showed no interactions.

Conclusion
In this population treated mainly with new generation DES, diabetic patients presented an increased risk of repeat revascularization across the spectrum of disease complexity.

Editorial Comment
In the FREEDOM study, the Syntax score did not predict events neither in patients receiving PCI or CABG. The SYNTAX showed just the opposite: events increased proportionally to score, basically given the higher rate of reinterventions.

To sum up, diabetes still has the highest impact on restenosis in the new DES era, even on simple lesions.