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(Circulation. 1996;94:1818-1825.)
© 1996 American Heart Association, Inc.
Articles |
the University of Pittsburgh, Pa (K.E.K., K.M.D., W.Y., S.F.K.), and the University of Southern California, Los Angeles (D.P.F., J.W.C.).
Correspondence to Kevin E. Kip, University of Pittsburgh, Graduate School of Public Health, Epidemiology Data Coordinating Center, 127 Parran Hall, 130 DeSoto St, Pittsburgh, PA 15261. E-mail epidkek@vms.cis.pitt.edu.
| Abstract |
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Methods and Results Data on baseline clinical and angiographic characteristics and short- and long-term outcomes of 281 diabetic and 1833 nondiabetic PTCA patients in the multicenter National Heart, Lung, and Blood Institute 1985-1986 PTCA Registry were analyzed. Diabetic patients were older, were more likely to be female, and had more comorbid baseline conditions, triple-vessel disease, and atherosclerotic lesions. Angiographic success and completeness of revascularization did not differ significantly, yet diabetic patients experienced more in-hospital death (women) and nonfatal myocardial infarction. Nine-year mortality was twice as high in diabetic patients (35.9% versus 17.9%). Similarly, 9-year rates of nonfatal myocardial infarction (29.0% versus 18.5%), bypass surgery (36.7% versus 27.4%), and repeat PTCA (43.7% versus 36.5%) were higher in diabetics than in nondiabetics. In multivariate analysis, diabetes remained a significant predictor of decreased 9-year survival and other untoward events.
Conclusions Compared with nondiabetic PTCA patients, diabetic patients have more extensive and diffuse atherosclerotic disease. Despite similar probability of angiographic success, diabetic patients are more likely to suffer in-hospital death (women) and nonfatal myocardial infarction. Long-term survival and freedom from myocardial infarction and coronary revascularization is also reduced in diabetic PTCA patients. Whether PTCA or coronary bypass surgery is more suitable for these patients is currently under investigation.
Key Words: myocardial infarction diabetes mellitus cardiovascular diseases angioplasty follow-up studies
| Introduction |
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To date, the short- and long-term outcomes of diabetic PTCA patients have not been well described from a cohort of patients with advanced and complex disease consistent with the present PTCA population and with procedures performed at multiple centers across North America. Therefore, we describe baseline clinical and angiographic characteristics and short- and long-term outcomes of diabetic PTCA patients from the NHLBI 1985 to 1986 PTCA Registry.
| Methods |
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Definitions
Coronary artery lesions were classified as proximal, mid, or distal in accordance with definitions in the Coronary Artery Surgery Study.25 Lesions in vein graft segments, however, were not included in lesion-level analyses despite the fact that 257 patients within the cohort (12%) had prior bypass surgery. This is because diabetic patients in the registry had slightly more prior bypass surgery than nondiabetic patients and because progression of atherosclerotic lesions may occur more rapidly in bypass graft segments.9 Thus, the number of angiographically-determined lesions was 3335. Successful dilatation was defined as >20% reduction in luminal diameter stenosis and <50% residual stenosis. This definition is consistent with the recommendation from the Joint International Society and Federation/World Health Organization Task Force on Coronary Angioplasty.26 Partial angiographic success was defined as successful dilation of at least one attempted lesion. Total angiographic success was defined as successful dilation of all attempted lesions.
MIs were documented by at least two of the following: clinical symptoms, ECG evidence (Q-wave criteria of a definite MI according to the Minnesota Code),27 and enzyme changes (more than double the upper normal limits of creatine kinase and/or the presence of creatine kinaseMB). Infarctions after hospitalization for initial PTCA were recorded whether they occurred alone, during a repeated PTCA, or during subsequent CABG. Hospital records were examined to verify that ECG findings, enzyme test results, and clinical symptoms were consistent with the registry definition of MI. Rates and risks of MI described throughout are for nonfatal MIs only. Repeated angioplasty was defined as a procedure performed after discharge from hospitalization for initial PTCA.
Follow-up
At each participating site, annual telephone interviews of the patients were conducted by the site coordinator. Information on hospitalizations for MI or repeated revascularization, angina, and cardiac catheterizations was collected and reported on standard forms. Information on diabetes treatment (insulin or hypoglycemic agent versus diet controlled) was not obtained during follow-up because it was not part of the standard forms and because no a priori hypotheses relative to diabetes were developed. At year 9 of follow-up, 1928 (91.2%) of the baseline cohort of 2114 patients were still providing follow-up information or had died. Of the remaining 186 patients of the total cohort (8.8%), 84 (4.0%) were lost to follow-up, 48 (2.3%) refused to be followed up, and contact was still being attempted in 54 (2.6%) of the patients. Among the 186 patients with incomplete follow-up, 21 (11.3%) were diabetic, and the mean length of follow-up was 5.1 and 5.2 years for diabetic and nondiabetics, respectively. Periodic searches of the National Death Index have been performed during the 9-year follow-up period to identify previously unknown deaths among patients with incomplete follow-up.
Statistical Analysis
The study population was analyzed in two ways. First, patients were categorized by the presence or absence of a history of diabetes. Second, the influence of diabetes was investigated as an independent predictor of morbid events. Differences in mean baseline and angiographic characteristics were analyzed by Student's t tests when continuous variables were normally distributed and by the Wilcoxon rank sum test when nonnormality was present. Differences in proportions of categorical variables were assessed by
2 tests. Logistic regression analysis was used to determine the OR of diabetes on in-hospital events while adjustment was made for baseline factors univariately associated with in-hospital outcomes (at P<.10). In-hospital outcomes included death, nonfatal MI, death/MI, abrupt closure, emergency surgery, and death/MI/emergency surgery. Life table analysis by use of the product-limit method was used to estimate short- and long-term morbid event rates by diabetes status. Cox regression analysis28 was used to assess the RR of diabetes on death and other untoward events at 9 years of follow-up. The covariate age was forced to remain in each model, with stepwise selection performed on the baseline factors univariately associated (at P<.05) with the outcome of interest. Graphic and analytic techniques were used to assess the proportional hazards assumption of invariant RR over the follow-up period. All analyses were performed with the use of SAS software (SAS Institute Inc).
| Results |
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Among angiographic characteristics (Table 2
), diabetic patients had similar ejection fractions (mean, 59%) but had more triple-vessel disease (27.7% versus 17.7%) and left dominance (21.1% versus 15.8%) than nondiabetics. In addition, diabetic patients had more total and significant lesions (lesions with
50% stenosis), particularly in the left anterior descending and left circumflex coronary arteries and in proximal and distal segments. The number of lesions attempted, pre-PTCA or post-PTCA stenoses, and rates of angiographic success did not differ by diabetes status; however, a slight but nonsignificant excess of incomplete revascularization was seen in the diabetic patients (61.1% versus 55.4% in nondiabetics; P=.08).
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Despite relatively similar procedural success, univariate analyses revealed that diabetic patients were significantly more likely to experience in-hospital death, nonfatal MI, and the combined outcomes of death/MI and death/MI/emergency surgery (Table 3
). After statistical adjustment, these relations diminished yet remained near or below statistical significance with an estimated risk of in-hospital death nearly three times higher in the diabetic group. The confidence limits for risk estimates of in-hospital outcomes were wide because of the sample size of diabetic patients and the relatively small number of events. Of note, all in-hospital deaths in the diabetic group occurred in female patients, which represents a striking female-specific death rate of 8.3%. A review of death certificate information and procedural comments provided by site operators and coordinators revealed that among these patients, four experienced MI, one experienced renal failure, one died of cardiogenic shock, one suffered left main occlusion with subsequent hypotension and renal insufficiency, and the remaining two patients experienced complications related to mitral value regurgitation/repair.
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Figs 1 through 5![]()
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present short- and long-term event rates by diabetes status. The 9-year death rate (Fig 1
) in diabetic patients was about double that of nondiabetic patients (35.9% versus 17.9%) and remained consistent across the number of diseased vessels (Fig 2
). Roughly 3% of the 18% excess death in the diabetic group occurred within the first 30 days of follow-up. After removing the excess in-hospital MI experienced in the diabetic group, the rate of nonfatal MI (Fig 3
) was similar between diabetic and nondiabetic patients up to 2 years of follow-up. During the subsequent 7 years of follow-up, a general increasing divergence in the rate of MI was seen, and at 9 years, the MI rate was about 1.6-fold higher in diabetic patients (29.0% versus 18.5%). Rates of CABG (Fig 4
) indicate increasing divergence between diabetic and nondiabetic patients, with diabetics undergoing about one third more CABG by 9 years of follow-up (36.7% versus 27.4%). Finally, rates of repeat PTCA (Fig 5
) were similar during the first 2 years, whereas throughout the remaining 7 years of follow-up, diabetic patients maintained an excess rate of repeat PTCA of
5% to 8%.
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In Cox regression analysis (Table 4
), diabetes conferred a >2-fold increased risk of death at 9 years univariately (RR: 2.28; 95% CI: 1.82, 2.85; P<.001) and an
80% increased risk (RR: 1.82; 95% CI: 1.41, 2.34; P<.001) after statistical adjustment for other baseline factors. Similarly, diabetes was a significant independent predictor of the combined outcomes of death/MI, death/MI/CABG, and repeat PTCA/CABG at 9 years of follow-up.
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| Discussion |
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From differences in baseline and angiographic characteristics, we expected a worse short-term outcome in diabetic patients. The 3.2% in-hospital death rate in diabetic patients is elevated compared with previously reported rates of 0% to 2%22 29 30 among PTCA recipients at large. The estimated near-threefold increased risk of in-hospital death among diabetic patients conflicts with a recent report13 in which very low rates (<0.5%) of in-hospital death were reported. The inconsistency may reflect cohort differences: in Stein et al,13 roughly 71% of patients had single-vessel disease and 2.5% had a history of congestive heart failure; corresponding proportions of 48.5% and 6.3% existed in our cohort. Still, it should be emphasized that no in-hospital-deaths occurred in male diabetic patients. Thus, the striking 8.3% in-hospital death rate in female diabetic patients and the observation that eight of these nine deaths involved cardiovascular complications strongly suggest increased periprocedural risk in female diabetic PTCA patients. However, in an ancillary study of 548 consecutive female PTCA patients treated from 1993 to 1994, no difference in in-hospital mortality was observed between diabetic and nondiabetic patients (2.6% versus 1.6%, respectively).
Diabetes was a borderline significant predictor of nonfatal in-hospital MI. MI as a complication of PTCA often occurs as a result of extensive coronary arterial dissection, intracoronary thrombosis, or both, with resultant vessel occlusion.31 In addition, some degree of intimal dissection is frequently observed after successful PTCA.32 Because diabetes is associated with abnormalities of platelet function, coagulation, fibrinolysis, endothelial function, and intraluminal thrombosis,33 as well as more extensive atherosclerotic disease (and perhaps more incomplete revascularization), diabetic PTCA patients may be predisposed to an elevated risk of in-hospital MI. Indeed, among the 93 patients who experienced nonfatal in-hospital MI, there was an apparent yet nonsignificant trend for diabetic patients to experience more in-hospital coronary dissection (21.6% versus 15.8%) and abrupt closure (31.6% versus 20.3%).
We expected diabetic patients to have more early revascularization because most revascularizations performed within the first 6 months of the index procedure are due to restenosis13 and because diabetes may increase the risk of restenosis after PTCA.14 15 16 However, rates of CABG and/or repeat PTCA at 6 months in the registry were generally similar across diabetes status. Because these results conflict with Stein et al,13 who suggested overall higher restenosis in diabetic patients, we investigated whether sex modified the effect of diabetes on restenosis. Indeed, rates of CABG and repeat PTCA between male diabetics and nondiabetics at 6 months were similar (11.8% versus 10.4% and 15.6% versus 14.7%, respectively); however, female diabetics had considerably higher rates of repeat PTCA than nondiabetic women at 6 months (18.5% versus 10.9%). Moreover, we found that female diabetic patients were more likely to have unstable angina (a feature predictive of restenosis) than nondiabetic women (69.9% versus 58.7%; P=.04), whereas no difference in unstable angina was seen in men (51.5% versus 50.5%; P=NS). In summary, our results suggest that higher restenosis, as inferred by higher rates of revascularization (repeat PTCA) within 6 months of follow-up, occur in female diabetics only.
The unadjusted and adjusted risk of death and combined 9-year outcomes were consistently higher in diabetic than nondiabetic patients, offering further evidence that diabetes adversely influences long-term prognosis after PTCA. Moreover, the excess risk of long-term mortality seen in diabetic PTCA patients is consistent with a recent report34 in which the 5-year PTCA mortality rate among randomized diabetes patients with multivessel disease was 35% compared with 19% in patients undergoing an initial revascularization strategy of CABG.
Study Limitations
This study has limitations. First, all PTCA procedures were performed in 1985 or 1986. Over the past decade, the field of interventional cardiology has experienced technological advances in guiding catheters, balloon catheters, and angioplasty wires; the advent and emergence of atherectomy devices, laser ablation devices, and stents; and increased use of platelet glycoprotein IIb/IIIa inhibitors. Revascularization strategies and procedural outcomes seen today may differ from those experienced by patients treated in 1985 or 1986. In particular, the association of diabetes with abnormalities in intraluminal thrombosis,33 a condition that may influence restenosis after PTCA35 may motivate more frequent use of stents in diabetic patients.
Second, because routine angiographic follow-up data were not collected for every patient, our conclusion that female diabetic patients are at increased risk of clinical restenosis, as inferred through higher rates of revascularization at 6 months, should be viewed tentatively. The apparently higher restenosis in female diabetic patients may be attributed in part to differential progression of or subsequent treatment for previously untreated lesions, particularly because diabetic patients indicated more diffuse disease. In the registry, angiographic disease was evaluated by PTCA operators and was not based on a central laboratory quantitative assessment of atherosclerotic burden. Therefore, imprecisions may exist in the magnitude of atherosclerotic disease and incidence of restenosis reported. Furthermore, diabetic patients may experience a higher incidence of silent ischemia, and thus, clinical detection of restenosis may be less reliable in diabetic patients.
Third, our ascertainment of diabetes through review of medical records and patient self-reports did not provide for determination of treatment status. Without a uniform, prospective definition of diabetes, some misclassification may have occurred, the probable net effect of which would be bias toward the null. Thus, our findings may reflect underestimates of the true adverse prognosis associated with diabetes in PTCA patients. However, because diabetes was not an a priori hypothesis, the findings herein should not be viewed as hypothesis based or confirmatory.
Finally, funding constraints precluded adjudication of MIs by an independent review committee. Because diabetic patients had a higher incidence of CABG over the follow-up period and because criteria used for discerning MI after CABG may differ from those of patients undergoing PTCA or spontaneous infarction, it is possible that differential criteria were used between diabetic and nondiabetic patients in discerning infarctions. Similarly, because hospital records were reviewed (ie, ECG evidence and enzyme values) in a nonblinded fashion, it is possible that known patient status of diabetes differentially influenced ascertainment of MI.
Conclusions
Compared with nondiabetic PTCA patients, diabetic patients tend to have more extensive and diffuse atherosclerotic disease and more comorbid baseline conditions. Despite similar probability of angiographic success, diabetic patients are more likely to suffer in-hospital death (females) and nonfatal MI. Moreover, the risk of restenosis may be exceptionally high in female diabetic patients. After accounting for more adverse baseline conditions, the risk of long-term mortality and other adverse outcomes in diabetic PTCA patients is significantly higher than in nondiabetic patients. Whether PTCA or CABG is more suitable for diabetic patients is currently under investigation.
| Selected Abbreviations and Acronyms |
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| Acknowledgments |
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Received June 19, 1996; revision received July 25, 1996; accepted July 31, 1996.
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J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): 652 - 726. [Full Text] [PDF] |
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P. Jimenez-Quevedo, M. Sabate, D. J. Angiolillo, F. Alfonso, R. Hernandez-Antolin, M. SanMartin, J. A. Gomez-Hospital, C. Banuelos, J. Escaned, R. Moreno, et al. Long-term clinical benefit of sirolimus-eluting stent implantation in diabetic patients with de novo coronary stenoses: long-term results of the DIABETES trial Eur. Heart J., August 2, 2007; 28(16): 1946 - 1952. [Abstract] [Full Text] [PDF] |
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W. Hueb, B. J. Gersh, F. Costa, N. Lopes, P. R. Soares, P. Dutra, F. Jatene, A. C. Pereira, A. F.T. Gois, S. A. Oliveira, et al. Impact of Diabetes on Five-Year Outcomes of Patients With Multivessel Coronary Artery Disease Ann. Thorac. Surg., January 1, 2007; 83(1): 93 - 99. [Abstract] [Full Text] [PDF] |
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H. Futamatsu, M. Sabate, D. J. Angiolillo, P. Jimenez-Quevedo, C. Corros, K. Morikawa-Futamatsu, F. Alfonso, J. Jiang, P. Cervinka, R. Hernandez-Antolin, et al. Characterization of Plaque Prolapse After Drug-Eluting Stent Implantation in Diabetic Patients: A Three-Dimensional Volumetric Intravascular Ultrasound Outcome Study J. Am. Coll. Cardiol., September 19, 2006; 48(6): 1139 - 1145. [Abstract] [Full Text] [PDF] |
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S J Hong, M H Kim, T H Ahn, Y K Ahn, J H Bae, W J Shim, Y M Ro, and D-S Lim Multiple predictors of coronary restenosis after drug-eluting stent implantation in patients with diabetes Heart, August 1, 2006; 92(8): 1119 - 1124. [Abstract] [Full Text] [PDF] |
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P. R. Soares, W. A. Hueb, P. A. Lemos, N. Lopes, E. E. Martinez, L. A.M. Cesar, S. A. Oliveira, and J. A.F. Ramires Coronary Revascularization (Surgical or Percutaneous) Decreases Mortality After the First Year in Diabetic Subjects but not in Nondiabetic Subjects With Multivessel Disease: An Analysis From the Medicine, Angioplasty, or Surgery Study (MASS II) Circulation, July 4, 2006; 114(1_suppl): I-420 - I-424. [Abstract] [Full Text] [PDF] |
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P. Jimenez-Quevedo, M. Sabate, D. J. Angiolillo, M. A. Costa, F. Alfonso, J. A. Gomez-Hospital, R. Hernandez-Antolin, C. Banuelos, J. Goicolea, F. Fernandez-Aviles, et al. Vascular Effects of Sirolimus-Eluting Versus Bare-Metal Stents in Diabetic Patients: Three-Dimensional Ultrasound Results of the Diabetes and Sirolimus-Eluting Stent (DIABETES) Trial J. Am. Coll. Cardiol., June 6, 2006; 47(11): 2172 - 2179. [Abstract] [Full Text] [PDF] |
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M. E. Williams Coronary Revascularization in Diabetic Chronic Kidney Disease/End-Stage Renal Disease: A Nephrologist's Perspective Clin. J. Am. Soc. Nephrol., March 1, 2006; 1(2): 209 - 220. [Full Text] [PDF] |
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P. Jimenez-Quevedo, M. Sabate, D. Angiolillo, F. Alfonso, R. Hernandez-Antolin, C. Banuelos, E. Bernardo, C. Ramirez, R. Moreno, C. Fernandez, et al. LDL-cholesterol predicts negative coronary artery remodelling in diabetic patients: an intravascular ultrasound study Eur. Heart J., November 1, 2005; 26(21): 2307 - 2312. [Abstract] [Full Text] [PDF] |
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M. Sabate, P. Jimenez-Quevedo, D. J. Angiolillo, J. A. Gomez-Hospital, F. Alfonso, R. Hernandez-Antolin, J. Goicolea, C. Banuelos, J. Escaned, R. Moreno, et al. Randomized Comparison of Sirolimus-Eluting Stent Versus Standard Stent for Percutaneous Coronary Revascularization in Diabetic Patients: The Diabetes and Sirolimus-Eluting Stent (DIABETES) Trial Circulation, October 4, 2005; 112(14): 2175 - 2183. [Abstract] [Full Text] [PDF] |
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D. M Safley and S. P Marso Diabetes and percutaneous coronary intervention in the setting of an acute coronary syndrome Diabetes and Vascular Disease Research, October 1, 2005; 2(3): 128 - 135. [Abstract] [PDF] |
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S. Varma, B. K. Lal, R. Zheng, J. W. Breslin, S. Saito, P. J. Pappas, R. W. Hobson II, and W. N. Duran Hyperglycemia alters PI3k and Akt signaling and leads to endothelial cell proliferative dysfunction Am J Physiol Heart Circ Physiol, October 1, 2005; 289(4): H1744 - H1751. [Abstract] [Full Text] [PDF] |
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S. B. King III, G. Dangas, J. W. Moses, S. B. King III, G. Dangas, and J. W. Moses Surgery Is Preferred for the Diabetic With Multivessel Disease Circulation, September 6, 2005; 112(10): 1500 - 1515. [Full Text] [PDF] |
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B. Stratmann and D. Tschoepe Pathobiology and cell interactions of platelets in diabetes Diabetes and Vascular Disease Research, February 1, 2005; 2(1): 16 - 23. [Abstract] [PDF] |
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M. Sabate, G. Pimentel, C. Prieto, J. Corral, C. Banuelos, D. J. Angiolillo, F. Alfonso, R. Hernandez-Antolin, J. Escaned, P. Fantidis, et al. Intracoronary brachytherapy after stenting de novo lesions in diabetic patients: Results of a randomized intravascular ultrasound study J. Am. Coll. Cardiol., August 4, 2004; 44(3): 520 - 527. [Abstract] [Full Text] [PDF] |
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C. Locker, R. Mohr, O. Lev-Ran, G. Uretzky, A. Frimerman, Y. Shaham, and I. Shapira Comparison of bilateral thoracic artery grafting with percutaneous coronary interventions in diabetic patients Ann. Thorac. Surg., August 1, 2004; 78(2): 471 - 475. [Abstract] [Full Text] [PDF] |
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S. J. Brener, B. W. Lytle, I. P. Casserly, J. P. Schneider, E. J. Topol, and M. S. Lauer Propensity Analysis of Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease and High-Risk Features Circulation, May 18, 2004; 109(19): 2290 - 2295. [Abstract] [Full Text] [PDF] |
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S. R. Wilson, B. A. Vakili, W. Sherman, T. A. Sanborn, and D. L. Brown Effect of Diabetes on Long-Term Mortality Following Contemporary Percutaneous Coronary Intervention: Analysis of 4,284 cases Diabetes Care, May 1, 2004; 27(5): 1137 - 1142. [Abstract] [Full Text] [PDF] |
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R. Mehran, G. D. Dangas, Y. Kobayashi, A. J. Lansky, G. S. Mintz, E. D. Aymong, M. Fahy, J. W. Moses, G. W. Stone, and M. B. Leon Short- and long-term results after multivessel stenting in diabetic patients J. Am. Coll. Cardiol., April 21, 2004; 43(8): 1348 - 1354. [Abstract] [Full Text] [PDF] |
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N. E.J. West, P. N. Ruygrok, C. M.C. Disco, M. W.I. Webster, W. K. Lindeboom, W. W. O'Neill, N. F. Mercado, and P. W. Serruys Clinical and Angiographic Predictors of Restenosis After Stent Deployment in Diabetic Patients Circulation, February 24, 2004; 109(7): 867 - 873. [Abstract] [Full Text] [PDF] |
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A. Norhammar, K. Malmberg, E. Diderholm, B. Lagerqvist, B. Lindahl, L. Ryden, and L. Wallentin Diabetes mellitus: the major risk factor in unstable coronary artery disease even after consideration of the extent of coronary artery disease and benefits of revascularization J. Am. Coll. Cardiol., February 18, 2004; 43(4): 585 - 591. [Abstract] [Full Text] [PDF] |
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R. Kornowski and S. Fuchs Optimization of glycemic control and restenosis prevention in diabetic patients undergoing percutaneous coronary interventions J. Am. Coll. Cardiol., January 7, 2004; 43(1): 15 - 17. [Full Text] [PDF] |
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S. Oparil Improving outcomes for women after coronary artery bypass grafting: A case for prevention J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 1704 - 1706. [Full Text] [PDF] |
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R. T. Hurst and R. W. Lee Increased Incidence of Coronary Atherosclerosis in Type 2 Diabetes Mellitus: Mechanisms and Management Ann Intern Med, November 18, 2003; 139(10): 824 - 834. [Abstract] [Full Text] [PDF] |
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T. F. Luscher, M. A. Creager, J. A. Beckman, and F. Cosentino Diabetes and Vascular Disease: Pathophysiology, Clinical Consequences, and Medical Therapy: Part II Circulation, September 30, 2003; 108(13): 1655 - 1661. [Full Text] [PDF] |
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M. Endo, Y. Tomizawa, and H. Nishida Bilateral Versus Unilateral Internal Mammary Revascularization in Patients With Diabetes Circulation, September 16, 2003; 108(11): 1343 - 1349. [Abstract] [Full Text] [PDF] |
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I. L Williams, B. Noronha, and A. G Zaman Review: The management of acute myocardial infarction in patients with diabetes mellitus The British Journal of Diabetes & Vascular Disease, September 1, 2003; 3(5): 319 - 324. [Abstract] [PDF] |
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J. A. Colwell and R. W. Nesto The Platelet in Diabetes: Focus on prevention of ischemic events Diabetes Care, July 1, 2003; 26(7): 2181 - 2188. [Abstract] [Full Text] [PDF] |
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K.-H. Mak and D. P. Faxon Clinical studies on coronary revascularization in patients with type 2 diabetes Eur. Heart J., June 2, 2003; 24(12): 1087 - 1103. [Abstract] [Full Text] [PDF] |
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T. M. Sundt III, B. J. Gersh, and H. C. Smith Indications for Coronary Revascularization Card. Surg. Adult, January 1, 2003; 2(2003): 541 - 559. [Full Text] |
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M. Ruel, R. A. Kelly, and F. W. Sellke Therapeutic Angiogenesis, Transmyocardial Laser Revascularization, and Cell Therapy Card. Surg. Adult, January 1, 2003; 2(2003): 715 - 750. [Full Text] |
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M. Laakso and J. Kuusisto Diabetology for cardiologists Eur. Heart J. Suppl., January 1, 2003; 5(suppl_B): B5 - B13. [Abstract] [PDF] |
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S. P Marso Review: The pathogenesis of type 2 diabetes and cardiovascular disease The British Journal of Diabetes & Vascular Disease, September 1, 2002; 2(5): 350 - 356. [Abstract] [PDF] |
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E. Van Belle, M. Perie, D. Braune, A. Chmait, T. Meurice, K. Abolmaali, E. P. McFadden, C. Bauters, J.-M. Lablanche, and M. E. Bertrand effects of coronary stenting on vessel patency and long-term clinical outcome after percutaneous coronary revascularization in diabetic patients J. Am. Coll. Cardiol., August 7, 2002; 40(3): 410 - 417. [Abstract] [Full Text] [PDF] |
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L. Gruberg, R. Waksman, A. E. Ajani, H.-S. Kim, R. L. White, E. E. Pinnow, L. F. Satler, A. D. Pichard, K. M. Kent, and J. Lindsay Jr The effect of intracoronary radiation for the treatment of recurrent in-stent restenosis in patients with diabetes mellitus J. Am. Coll. Cardiol., June 19, 2002; 39(12): 1930 - 1936. [Abstract] [Full Text] [PDF] |
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J. A. Beckman, M. A. Creager, and P. Libby Diabetes and Atherosclerosis: Epidemiology, Pathophysiology, and Management JAMA, May 15, 2002; 287(19): 2570 - 2581. [Abstract] [Full Text] [PDF] |
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S. C. Smith Jr, D. Faxon, W. Cascio, H. Schaff, T. Gardner, A. Jacobs, S. Nissen, and R. Stouffer Prevention Conference VI: Diabetes and Cardiovascular Disease: Writing Group VI: Revascularization in Diabetic Patients Circulation, May 7, 2002; 105 (18): e165 - e169. [Full Text] [PDF] |
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G. Heper, T. Durmaz, S. Namik Murat, and E. Ornek Clinical and Angiographic Outcomes of Diabetic Patients After Coronary Stenting: A Comparison of Native Vessel Stent Restenosis Rates in Different Diabetic Subgroups Angiology, May 1, 2002; 53(3): 287 - 295. [Abstract] [PDF] |
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R. Scognamiglio, A. Avogaro, S. Vigili de Kreutzenberg, C. Negut, M. Palisi, E. Bagolin, and A. Tiengo Effects of Treatment With Sulfonylurea Drugs or Insulin on Ischemia-Induced Myocardial Dysfunction in Type 2 Diabetes Diabetes, March 1, 2002; 51(3): 808 - 812. [Abstract] [Full Text] [PDF] |
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E. Erdmann Cardiovascular events in patients with type 2 diabetes The British Journal of Diabetes & Vascular Disease, January 1, 2002; 2(1_suppl): S4 - S8. [Abstract] [PDF] |
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M. J. Magee, T. M. Dewey, T. Acuff, J. R. Edgerton, J. F. Hebeler, S. L. Prince, and M. J. Mack Influence of diabetes on mortality and morbidity: off-pump coronary artery bypass grafting versus coronary artery bypass grafting with cardiopulmonary bypass Ann. Thorac. Surg., September 1, 2001; 72(3): 776 - 781. [Abstract] [Full Text] [PDF] |
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A. Abizaid, M. A. Costa, M. Centemero, A. S. Abizaid, V. M.G. Legrand, R. V. Limet, G. Schuler, F. W. Mohr, W. Lindeboom, A. G.M.R. Sousa, et al. Clinical and Economic Impact of Diabetes Mellitus on Percutaneous and Surgical Treatment of Multivessel Coronary Disease Patients: Insights From the Arterial Revascularization Therapy Study (ARTS) Trial Circulation, July 31, 2001; 104(5): 533 - 538. [Abstract] [Full Text] [PDF] |
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C.V Patil, E Nikolsky, M Boulos, E Grenadier, and R Beyar Multivessel coronary artery disease: current revascularization strategies Eur. Heart J., July 2, 2001; 22(14): 1183 - 1197. [PDF] |
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C. Indolfi, D. Torella, L. Cavuto, A. M. Davalli, C. Coppola, G. Esposito, M. V. Carriero, A. Rapacciuolo, E. Di Lorenzo, E. Stabile, et al. Effects of Balloon Injury on Neointimal Hyperplasia in Streptozotocin-Induced Diabetes and in Hyperinsulinemic Nondiabetic Pancreatic Islet-Transplanted Rats Circulation, June 19, 2001; 103(24): 2980 - 2986. [Abstract] [Full Text] [PDF] |
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N. W. Niles, P. D. McGrath, D. Malenka, H. Quinton, D. Wennberg, S. J. Shubrooks, J. F. Tryzelaar, R. Clough, M. J. Hearne, F. Hernandez Jr, et al. Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study J. Am. Coll. Cardiol., March 15, 2001; 37(4): 1008 - 1015. [Abstract] [Full Text] [PDF] |
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E. Van Belle, R. Ketelers, C. Bauters, M. Perie, K. Abolmaali, F. Richard, J.-M. Lablanche, E. P. McFadden, and M. E. Bertrand Patency of Percutaneous Transluminal Coronary Angioplasty Sites at 6-Month Angiographic Follow-Up : A Key Determinant of Survival in Diabetics After Coronary Balloon Angioplasty Circulation, March 6, 2001; 103(9): 1218 - 1224. [Abstract] [Full Text] [PDF] |
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W. A. Hsueh, S. Jackson, and R. E. Law Control of Vascular Cell Proliferation and Migration by PPAR-{gamma}: A new approach to the macrovascular complications of diabetes Diabetes Care, February 1, 2001; 24(2): 392 - 397. [Abstract] [Full Text] |
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P. Theroux, J. Alexander Jr, C. Pharand, E. Barr, S. Snapinn, A. F. Ghannam, and F. L. Sax Glycoprotein IIb/IIIa Receptor Blockade Improves Outcomes in Diabetic Patients Presenting With Unstable Angina/Non-ST-Elevation Myocardial Infarction : Results From the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Circulation, November 14, 2000; 102(20): 2466 - 2472. [Abstract] [Full Text] [PDF] |
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Y Otsuka, S Miyazaki, H Okumura, S Yasuda, S Daikoku, I Morii, Y Sutani, Y Goto, and H Nonogi Abnormal glucose tolerance, not small vessel diameter, is a determinant of long-term prognosis in patients treated with balloon coronary angioplasty Eur. Heart J., November 1, 2000; 21(21): 1790 - 1796. [Abstract] [PDF] |
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J. M. Ahmed, M. K. Hong, R. Mehran, G. Dangas, G. S. Mintz, A. D. Pichard, L. F. Satler, K. M. Kent, H. Wu, G. W. Stone, et al. Influence of diabetes mellitus on early and late clinical outcomes in saphenous vein graft stenting J. Am. Coll. Cardiol., October 1, 2000; 36(4): 1186 - 1193. [Abstract] [Full Text] [PDF] |
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E. Braunwald, E. M. Antman, J. W. Beasley, R. M. Califf, M. D. Cheitlin, J. S. Hochman, R. H. Jones, D. Kereiakes, J. Kupersmith, T. N. Levin, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina) J. Am. Coll. Cardiol., September 1, 2000; 36(3): 970 - 1062. [Full Text] [PDF] |
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D. M. Shindler, S. T. Palmeri, T. A. Antonelli, L. A. Sleeper, J. Boland, T. P. Cocke, J. S. Hochman, and for the SHOCK Investigators Diabetes mellitus in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry J. Am. Coll. Cardiol., September 1, 2000; 36(3_Suppl_A): 1097 - 1103. [Abstract] [Full Text] [PDF] |
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T. Hammoud, J.-F. Tanguay, and M. G. Bourassa Management of coronary artery disease: therapeutic options in patients with diabetes J. Am. Coll. Cardiol., August 1, 2000; 36(2): 355 - 365. [Abstract] [Full Text] [PDF] |
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A.M. Lincoff and E.J. Topol Platelet glycoprotein IIb/IIIa inhibition during percutaneous coronary revascularization: what more needs to be proven? Eur. Heart J., June 1, 2000; 21(11): 863 - 867. [PDF] |
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A. Chajara, M. Raoudi, B. Delpech, M. Leroy, J. P. Basuyau, and H. Levesque Increased Hyaluronan and Hyaluronidase Production and Hyaluronan Degradation in Injured Aorta of Insulin-Resistant Rats Arterioscler Thromb Vasc Biol, June 1, 2000; 20(6): 1480 - 1487. [Abstract] [Full Text] [PDF] |
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D. Hasdai, C. B. Granger, S. S. Srivatsa, D. A. Criger, S. G. Ellis, R. M. Califf, E. J. Topol, and D. R. Holmes Jr. Diabetes mellitus and outcome after primary coronary angioplasty for acute myocardial infarction: lessons from the GUSTO-IIb angioplasty substudy J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1502 - 1512. [Abstract] [Full Text] [PDF] |
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J. Schofer, M. Schluter, T. Rau, F. Hammer, N. Haag, and D. G. Mathey Influence of treatment modality on angiographic outcome after coronary stenting in diabetic patients: a controlled study J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1554 - 1559. [Abstract] [Full Text] [PDF] |
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W. C Krupski, M. R Nehler, T. A Whitehill, R. C Lawson, P. K Strecker, and W. R Hiatt Negative impact of cardiac evaluation before vascular surgery Vascular Medicine, February 1, 2000; 5(1): 3 - 9. [Abstract] [PDF] |
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W. C. Krupski Expert Commentary Perspectives in Vascular Surgery and Endovascular Therapy, January 1, 2000; 12(2): 43 - 48. [PDF] |
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S. R. Steinhubl, K. Kottke-Marchant, D. J. Moliterno, M. L. Rosenthal, N. K. Godfrey, B. S. Coller, E. J. Topol, and A. M. Lincoff Attainment and Maintenance of Platelet Inhibition Through Standard Dosing of Abciximab in Diabetic and Nondiabetic Patients Undergoing Percutaneous Coronary Intervention Circulation, November 9, 1999; 100(19): 1977 - 1982. [Abstract] [Full Text] [PDF] |
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P. R. Moreno, J. T. Fallon, A. M. Murcia, M. N. Leon, H. Simosa, V. Fuster, and I. F. Palacios Tissue characteristics of restenosis after percutaneous transluminal coronary angioplasty in diabetic patients J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1045 - 1049. [Abstract] [Full Text] [PDF] |
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S. M. Grundy, I. J. Benjamin, G. L. Burke, A. Chait, R. H. Eckel, B. V. Howard, W. Mitch, S. C. Smith Jr, and J. R. Sowers Diabetes and Cardiovascular Disease : A Statement for Healthcare Professionals From the American Heart Association Circulation, September 7, 1999; 100(10): 1134 - 1146. [Full Text] [PDF] |
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E. Van Belle, K. Abolmaali, C. Bauters, E. P. McFadden, J.-M. Lablanche, and M. E. Bertrand Restenosis, late vessel occlusion and left ventricular function six months after balloon angioplasty in diabetic patients J. Am. Coll. Cardiol., August 1, 1999; 34(2): 476 - 485. [Abstract] [Full Text] [PDF] |
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H. Schunkert, L. Harrell, and I. F. Palacios Implications of small reference vessel diameter in patients undergoing percutaneous coronary revascularization J. Am. Coll. Cardiol., July 1, 1999; 34(1): 40 - 48. [Abstract] [Full Text] [PDF] |
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S. P. Marso, S. G. Ellis, E. M. Tuzcu, P. L. Whitlow, I. Franco, R. E. Raymond, and E. J. Topol The importance of proteinuria as a determinant of mortality following percutaneous coronary revascularization in diabetics J. Am. Coll. Cardiol., April 1, 1999; 33(5): 1269 - 1277. [Abstract] [Full Text] [PDF] |
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R. E. Kuntz Importance of Considering Atherosclerosis Progression When Choosing a Coronary Revascularization Strategy : The Diabetes–Percutaneous Transluminal Coronary Angioplasty Dilemma Circulation, February 23, 1999; 99(7): 847 - 851. [Full Text] [PDF] |
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S. Elezi, A. Kastrati, J.u. Pache, A. Wehinger, M. Hadamitzky, J. Dirschinger, F.-J. Neumann, and A. Schomig Diabetes mellitus and the clinical and angiographic outcome after coronary stent placement J. Am. Coll. Cardiol., December 1, 1998; 32(7): 1866 - 1873. [Abstract] [Full Text] [PDF] |
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A. Abizaid, R. Kornowski, G. S. Mintz, M. K. Hong, A. S. Abizaid, R. Mehran, A. D. Pichard, K. M. Kent, L. F. Satler, H. Wu, et al. The influence of diabetes mellitus on acute and late clinical outcomes following coronary stent implantation J. Am. Coll. Cardiol., September 1, 1998; 32(3): 584 - 589. [Abstract] [Full Text] [PDF] |
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N. S. Kleiman, A. M. Lincoff, D. J. Kereiakes, D. P. Miller, F. V. Aguirre, K. M. Anderson, H. F. Weisman, R. M. Califf, and E. J. Topol Diabetes Mellitus, Glycoprotein IIb/IIIa Blockade, and Heparin : Evidence for a Complex Interaction in a Multicenter Trial Circulation, May 19, 1998; 97(19): 1912 - 1920. [Abstract] [Full Text] [PDF] |
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G. W. Barsness, E. D. Peterson, E. M. Ohman, C. L. Nelson, E. R. DeLong, J. G. Reves, P. K. Smith, R. D. Anderson, R. H. Jones, D. B. Mark, et al. Relationship Between Diabetes Mellitus and Long-term Survival After Coronary Bypass and Angioplasty Circulation, October 21, 1997; 96(8): 2551 - 2556. [Abstract] [Full Text] |
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T. B. Investigators Influence of Diabetes on 5-Year Mortality and Morbidity in a Randomized Trial Comparing CABG and PTCA in Patients With Multivessel Disease : The Bypass Angioplasty Revascularization Investigation (BARI) Circulation, September 16, 1997; 96(6): 1761 - 1769. [Abstract] [Full Text] |
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E. Van Belle, C. Bauters, E. Hubert, J.-C. Bodart, K. Abolmaali, T. Meurice, E. P. McFadden, J.-M. Lablanche, and M. E. Bertrand Restenosis Rates in Diabetic Patients : A Comparison of Coronary Stenting and Balloon Angioplasty in Native Coronary Vessels Circulation, September 2, 1997; 96(5): 1454 - 1460. [Abstract] [Full Text] |
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R. Kornowski, G. S. Mintz, K. M. Kent, A. D. Pichard, L. F. Satler, T. A. Bucher, M. K. Hong, J. J. Popma, and M. B. Leon Increased Restenosis in Diabetes Mellitus After Coronary Interventions Is Due to Exaggerated Intimal Hyperplasia: A Serial Intravascular Ultrasound Study Circulation, March 18, 1997; 95(6): 1366 - 1369. [Abstract] [Full Text] |
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MORE EVIDENCE ON RISK OF PTCA IN DIABETICS Journal Watch (General), October 25, 1996; 1996(1025): 10 - 10. [Full Text] |
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S. Goldberg, M. P. Savage, and D. L. Fischman The Interventional Cardiologist and the Diabetic Patient: Have We Pushed the Envelope Too Far or Not Far Enough? Circulation, October 15, 1996; 94(8): 1804 - 1806. [Full Text] |
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K. E. Kip, E. L. Alderman, M. G. Bourassa, M. M. Brooks, L. Schwartz, D. R. Holmes Jr, R. M. Califf, P. L. Whitlow, B. R. Chaitman, and K. M. Detre Differential Influence of Diabetes Mellitus on Increased Jeopardized Myocardium After Initial Angioplasty or Bypass Surgery: Bypass Angioplasty Revascularization Investigation Circulation, April 23, 2002; 105(16): 1914 - 1920. [Abstract] [Full Text] [PDF] |
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