Prediabetic Patient Outcomes 8 to 15 Years After Drug-Eluting Coronary Stenting

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Guidelines suggest differential management of diabetics and nondiabetics with coronary artery disease (CAD) referred for revascularization, but pre-diabetics, who now comprise up to 20% to 30% of CAD patients, have been excluded from the diabetic group. To address this, we studied long-term cardiac outcomes in 1,323 consecutively drug-eluting stent (DES)-stented patients from prespecified local zip codes, dividing patients into normal-glycemic patients, prediabetics and diabetics, based upon conventional definitions. Patient age was 63±11 years, 65.5% male, mean baseline SYNTAX score of 10.2±6.8 and residual SYNTAX score=3.0±4.6. Only 2.9% of patients were lost to follow up at 10 years. Duration of follow up for alive patients was 124±33 mos. Major adverse cardiac events (MACE) by Kaplan Meier (KM) was similar for normal glycemics and prediabetics (42.9±2.5% vs 38.6±3.1% at 10 years, p=0.35), whereas that for diabetics was worse (56.7±2.6% at 10 years, p<0.001 vs prediabetics). KM cardiac death rates at 10 years were 14.2±1.8%, 16.0±2.4% and 31.2±2.3% for normal glycemics, prediabetics, and diabetics, respectively (p=0.34 and p<0.001 [covariate adjusted p=0.018] for prediabetics versus normal glycemics and versus diabetics, respectively). We found that prediabetics have long-term post-DES outcomes far more similar to those of normal-glycemic patients than diabetics.

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Methods

Consecutive patients treated with any limus-eluting drug-eluting stent (DES) from 2004 through 2012 (to allow at least 8 year follow up) from Cuyahoga, Ashtabula or western Geauga counties were identified for follow up from our prospective post-PCI follow up registry. These sites were chosen a priori based upon likely patient follow up within our Health System. Diabetic status at baseline was ascertained by HbA1C and fasting blood sugar levels. Prediabetes was diagnosed using the American

Results

Baseline demographics, angiographic findings and initial treatment details for the 1,323 patients studied are shown in Tables 1, 2 and 3, respectively. There were 468 normal glycemic patients, 328 prediabetics and 502 diabetics (178 of whom required insulin). Twenty-five patients could not be classified for diabetic status with certainty. Findings are notable for patient age of 63±11 years, 65.5% male, mean baseline SYNTAX score of 10.2±6.8 and residual SYNTAX score=3.0±4.6. Only 2.9% of

Discussion

The principal finding in this study of nearly 10 year average follow up (and very few lost to follow up) was that prediabetics, in general, had post-DES clinical outcomes very similar to normal glycemic, non-diabetics and clearly superior to patients having diabetes at baseline.

There were, of course, differences in baseline characteristics that might partly explain these findings, including that prediabetics had less advanced coronary disease (e.g., SYNTAX score) and less renal insufficiency

Author Contributions

Stephen G. Ellis: Conceptualization, Analysis, Writing Leslie Cho: Reviewing, Editing Russell Raymond: Reviewing, Editing Ravi Nair: Reviewing, Editing Conrad Simpfendorfer: Reviewing, Editing Murat Tuzcu: Reviewing, Editing Christopher Bajzer: Reviewing, Editing A. Michael Lincoff: Reviewing, Editing Samir Kapadia: Reviewing, Editing.

Disclosure

Regarding potential conflicts of interest, Dr. Ellis has been a consultant for Abbott Vascular, Biotronik, Boston Scientific and Medtronic while Dr. Bajzer is a proctor and speaker for Abbott Vascular. The other authors list no conflicts.

Conflicts of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

Special thanks to Georgiana Howell, Kathy Lander, Patrick Vargo and all the nurses and data technicians for maintaining the database from which the report derives, and to Candace Ristagno for assistance with the preparation of this manuscript.

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Funding: This work was supported by internal Cleveland Clinic sources.

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