Diabetic patients have twice as high a risk of developing coronary artery disease (CAD). Additionally, CAD increases mortality risk. Patients with a history of percutaneous coronary intervention (PCI) tend to need repeat revascularization, even with second generation stents. To date, there are few studies assessing the role of glycemic control in stent failure, stent thrombosis, and/or instent restenosis.
Santos-Pardo et al. carried out a nation-wide retrospective observational analysis in Sweden including patients with type II diabetes treated with second generation DES stenting for de novo lesions.
Glycemic control was assessed using glycated hemoglobin (HbA1c), with reference values between 6.1% and 7%.
Primary end point was instent restenosis or stent thrombosis to second generation stents implanted during the study period. It excluded patients with stent thrombosis within 30 days after PCI, seeing as these cases stem from thrombosis.
Secondary end points were individual primary end components, myocardial infarction and all-cause mortality.
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The total cohort included 24,411 patients receiving 29,029 DES. Mean patient age was 68, and 74% were men. Patients with HbA1c ≥7.1% were more often smokers, overweight, or had a history of dyslipidemia, acute myocardial infarction, stroke, kidney failure or CABG, vs. patients with 6% to 7% HbA1c.
Patients with high HbA1c values showed more multivessel disease, and frequently received less complete revascularization in the same procedure.
During mean 6.4 year followup, a total 1,873 stent failure events were observed. Groups were stratified according to HbA1c: the ≤5.5% subgroup had HR 1.10; those with 5.6% to 6%, had HR 1.02; in those between 7.1% and 8%, HR was 1.25; those between 8.1% and 9%, had HR 1.3; between 9.1% and 10%, had HR 1.46; and finally for HbA1c ≥10.1%, HR resulted 1.31.
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In the adjusted cohort, those with HbA1c ≥7.1% presented increased risk vs. reference values (HR 1.28; CI 95% 1.16-1.42). Relative risk of bad glycemic control was higher in patients younger than 65, with no significant differences between insulin dependent and non-dependent.
As regards secondary end points, there were 1,159 instent restenosis and 771 stent thrombosis cases. The higher risk of instent restenosis was seen in patients with HbA1c between 9.1% and 10% (HR 1.55; CI 95% 1.23-1.96), and when looking at stent thrombosis, patients at higher risk had HbA1c between 7.1% and 8% (HR 1.32; CI 95% 1.10-1.59).
As regards mortality, HbA1c ≥10.1% patients presented higher risk, with HR 1.65 (CI 95% 1.49-1.84). There were no significant differences in AMI risk between the different HbA1c categories.
Conclusions
According to the Swedish study, the risk of stent failure gradually increases as HbA1c levels increase, mainly due to instent restenosis, with progressive increase of risk (HR 1.3).
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Glycemic Control and Coronary Stent Failure in Patients With Type 2 Diabetes Mellitus.
Reference: Santos-Pardo I, Andersson Franko M, Lagerqvist B, Ritsinger V, Eliasson B, Witt N, Norhammar A, Nyström T. Glycemic Control and Coronary Stent Failure in Patients With Type 2 Diabetes Mellitus. J Am Coll Cardiol. 2024 May 7:S0735-1097(24)06933-X. doi: 10.1016/j.jacc.2024.04.012. Epub ahead of print. PMID: 38752901.
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