(Circulation. 2001;103:1185.)
© 2001 American Heart Association, Inc.
Editorial |
Acceleration of Restenosis by Diabetes
Pathogenetic Implications
From the Department of Medicine, University of Vermont College of Medicine, Burlington.
Correspondence to Burton E. Sobel, MD, Department of Medicine, University of Vermont, Colchester Research Facility, 208 S Park Dr, Colchester, VT 05446. E-mail burton.sobel@vtmednet.org
Key Words: Editorials • stents • acute coronary syndromes • coronary interventions
Van Belle et al,1 who were among the first to emphasize the potential importance of diabetes in adverse late outcomes after percutaneous coronary interventions (PCI), provide useful observations in their present study of a large cohort of diabetic patients who were treated with standard balloon angioplasty, scheduled for repeated angiography 6 months later, and followed for an average of 6.5 years. They conclude that the incidence of both nonocclusive and occlusive restenosis is higher in diabetic subjects as judged from comparison with historical control subjects. Furthermore, they report that occlusive restenosis is "a strong, independent correlate of long-term mortality." These results implicate accelerated restenosis as both a consequence of diabetes and a cause for increased mortality after PCI in diabetic patients. They are consistent with results in prospective, long-term–mortality, controlled trials2 3 and with results in observational mortality and angiographic studies.4 5
Observations such as those reported by Van Belle et al
raise important clinical questions. One is whether either surgery or
PCI is a preferred initial treatment strategy for patients with
diabetes who require coronary revascularization. The advent and wide
utilization of stents, powerful antiplatelet agents, and technological
advances after enrollment in the studies cited above had been largely
completed makes extrapolation difficult and precludes a definitive
answer. However, stenting does not obviate accelerated restenosis with
diabetes6 even though it
reduces its incidence in some patients and in some types of
vessels.7 Furthermore, in
patients with diabetes who sustain myocardial infarction after
previous, remote revascularization, mortality is lower when the
antecedent
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