REVASCULARIZATON IN PATIENTS WITH DIABETES MELLITUS: OPTIMAL APPROACH IN 2017
Gregory W. Barsness, M.D., Mayo Clinic, Rochester, MN, USA
Background: Diabetes mellitus is a growing worldwide problem, affecting 28 million patients in the US, with another 80 million at risk due to obesity and related disorders. Diabetes mellitus is associated with significant health and social costs, with an estimated annual economic toll of $322 billion dollars in the US. In addition, surgical and percutaneous revascularization outcomes are impaired in the setting of diabetes mellitus, requiring careful individualized consideration of the need and optimal choice of revascularization strategy.
Results: Diabetes mellitus is associated with a 2-5 fold increased risk of premature, diffuse coronary disease resulting in an increased risk of acute coronary syndrome and death. A disadvantageous metabolic milieu creates an environment hostile to favorable long-term revascularization results with an increased risk of lesion development, progression and restenosis. Optimal medical therapy and risk factor modification has been shown to significantly improve cardiovascular outcomes independent of the choice of revascularization strategy. Compared with percutaneous revascularization (PCI), coronary bypass grafting (CABG) is associated with reduced MACE in higher risk patients with multivessel disease despite an increased early risk of stroke, particularly in patients with LM disease and more complex anatomy.
Conclusion: In asymptomatic or minimally symptomatic diabetic patients with coronary artery disease, optimal medical therapy remains the preferred initial treatment strategy and the foundation of sound management. Patients at higher risk due to multivessel disease and large ischemic burden may benefit from early revascularization. An individualized, patient-centric heart team approach, including consideration of coronary anatomy, risk profile, presentation features and patient preference is essential. Ongoing medical, surgical and percutaneous developments require continuous reassessment of relative risks and benefits associated with these modalities to ensure optimal outcome in patients with diabetes mellitus.