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Varioustherapeutic proportion of the patients
来源:Capital University of Medical Science | 作者:sjzxads | 发布时间:2013-7-19 访问人数: 241

Varioustherapeutic proportion of the patients with type 2 diabetes mellitus undergonecoronary angiography in the era of development in MSCT

 

Feng Liang1,Zhujun Shen 2, Dayi Hu 3, Mingying Wu4,Tianchang Li4,Chuzhong Tang4,Jiyun Wang4,Changlin Lu4,Xiuhua Ma 1#

1Department of Cardiology,Daxing Hospital, Capital University of Medical Science, Beijing, 102600, China (Feng Liang, Xiuhua Ma)

2Department of Cardiology,Beijing Union Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China(ZhujunShen)

3Cardiaccenter, Beijing People’s Hospital, Beijing University, Beijing, 100044, China (DayiHu)

4Cardiaccenter, Beijing Tongren Hospital,Capital University of Medical Science, Beijing, 100730, China(Mingying Wu,Tianchang Li,Chuzhong Tang,Jiyun Wang,Changlin Lu)

Abstract

Introduction: Diabeticpatients are prone to a diffuse and rapidly progressive form ofatherosclerosis, which increases their likelihood of requiring revascularization,particularly for CABG. This study was to examin the various therapeuticproportion of the population of the patients with type 2 diabetes mellitusundergone coronary angiography(CAG) in the era of development in MSCT in thereal clinical practice.

Methods: 1406consecutive patients were undergone CAG, of which patients, 351 patients with  type 2 diabetes mellitus, 1055 without that. Byevaluating the coronary angiogram, the patients were not diagnosed to havecoronary heart disease(CHD) with less than 50% diameter stenosis of coronaryartery; CHD was defined as narrowing of the appropriate lumen of ≥ 50%; theprocedure of percutaneous coronary intervention(PCI) were performed in thepatients with more than or equal to 70% stenosis lesions, the decision makingfor PCI mainly based on the clinical demonstration and the coronary lesionmorphologies, which were suitable for PCI; the coronary aortic bypass graft(CABG)surgery had been proposed based on the guideline.

Results: The baseline characteristics of patients with and without diabetes undergonecoronary angiography were as following. The age was significantly older inpatients with diabetes than without diabetes(60.22±9.70 versus 57.76±9.94, p<0.0005). More femal patients in thediabetes group than non-diabetes group(45.30% versus 35.55%, p<0.0005). The morbidity rate ofUAP  (64.96% and 49.86%, p<0.0005), and Hypertension (80.06%and 69.57%, p<0.0005) weresignificantly higher in patients with diabetes than without diabetes.

By evaluating the coronary angiogram, more patients were diagnosedto CHD in the diabetes group than in the non-diabetic group(92.59% versus 79.43%,p<0.0005); theproportion of the population of the patients with CHD not requiring for PCI andperformed the procedure of stent implantation were almost idetical in the twogroups(23.30% versus 25.97%, p=0.33; 35.61% versus 32.61%, p=0.30, respectively);more patients with CHD were proposed to perform the CABG in the diabetes groupthan in the non-diabetic group(31.91% versus 17.35%, p<0.0005).

Conclusion: The morbidity rate of coronary heart disease among patientswith type 2 diabetes is greater than non- diabetes, patients withtype 2 diabetes have a significantly higher rate of coronary artery bypassgrafting which had been proposed.

Keywords:Diabetes mellitus; Coronary heart disease; Percutaneous coronary intervention;Coronary aortic bypass graft surgery; coronary risk factors.

 

Introduction

 

Patients with type 2 diabetes(2 DM) often have multiple cardiac risk factors, including hypertension in~50–60% ofindividuals, dyslipidemia, inactivity, smoking, and abdominal obesity. Multiplerisk factors in the same patient substantially increase the overallcardiovascular risk[1-3]. Diabetes is animportant risk factor for poor outcomes after elective percutaneous coronary intervention(PCI). In particular, diabetic patients are prone to a diffuse and rapidly progressiveform of atherosclerosis, which increases their likelihood of requiring revascularization[4,5].

previous studies havedocumented a greater prevalence of severe multivessel coronary artery diseaseamong patients with diabetes compared with those without diabetes, even in theabsence of prior symptoms or clinical evidence of disease[6]. Theclinical and angiographical findings are quite different in coronary heartdisease(CHD) patients with and without type 2 DM. The lesions in the coronaryarteries tend to be more diffuse and severer in patients with type 2 DM. This study was to examin the various therapeutic proportion of thepopulation of the patients with type 2 diabetes mellitus undergone coronaryangiography in the era of development in multislice spiral computed tomography(MSCT)in the real clinical practice.


Patients and Methods

 

Patient selection

One thousand four hundred and six consecutivepatients, who underwent coronaryangiography (CAG) at daxing hospital from February 2007through to March 2010, were enrolled. The general laboratory test were examined inall patients after admission, including blood and urine routine test, serumbiochemical test, chest X-ray check, electrocardiography(ECG), ultrasonic cardiography(UCG), ultrasonography forliver and kidney. Dynamic electrocardiography (DCG) and MSCT (GE Inc) wereexamined in part of the patients. All patients wereindicated for CAG by the clinical manifestations and the results of allnon-invasive examination, written informed consent of CAG was obtained from allpatients and their family members. The exclusion criteria included severe heartdysfunction, severe cardiac arrhythmia, patients with psychopathic diseases, severeother organ diseases apart from heart, knownhemorrhagic diathesis, serum creation32mg/dl, patients with STEMI received primarypercutaneous coronary intervention. Of  the 1406 patients,351 patients were diagnosed as type 2 diabetes mellitus, 1055 patients werediagnosed as non-diabetic mellitus after admission to hospital. Thediagnostic criteria for diabetes mellitus was refered to The Expert Committeeon the Diagnosis and Classification of Diabetes Mellitus published in 2003[7].

Diagnosesand selection of therapeutics by CAG

By evaluating the coronary angiogram, thepatients were not angiographically documented CHD without any significantlesion (≥50% diameterstenosis); CHD wasdefined as narrowing of the appropriate lumen of ≥50% in an anatomically relevant coronary artery segment. The procedureof percutaneous coronary intervention(PCI) were performed in the patients with ≥ 70% stenosis lesions, the decision making for PCI mainlybased on the clinical demonstration and the coronary lesion morphologies, whichwere suitable for PCI. The coronary aortic bypass graft (CABG) surgery had beenproposed in patients with significant left main coronary artery lesions, leftmain equivalent(70% diameter stenosis or more of both the proximal leftanterior descending and circumflex arteries), diffuse triple coronary arterylesions, two-vessel disease with significant proximal left anterior descendingCAD, however the determinations of the therapeutic choice were combined with theclinical data and CAD anatomy [8].

 

Statistical analysis

SPSS11.5statistical software was used for Statistical analysis, continuous variableswere expressed as mean±standard deviation, categoricalvariables were expressed as percent    proportions. continuous variables analysis were tested by the 2-tailed unpaired t-test, Univariate analysis was tested by thechi-square or Fisher’s exact tests. P value less than 0.05 was consideredstatistically significant.

Results

 

The baseline characteristics of patients with and without diabetics undergonecoronary angiography were as table 1. The age was older in patients with diabetesthan without diabetes(60.22±9.70 versus 57.76±9.94, p<0.0005). More femal patients in the diabetes group than non-diabetesgroup(45.30% versus 35.55%, p<0.0005). The morbidity rate of unstable angina pectoris(UAP) (64.96%and 49.86%, p<0.0005), and Hypertension(80.06% and 69.57%, p<0.0005) were significantly higher in patients with diabetes thanwithout diabetes.

By evaluating the coronary angiogram, more patients were diagnosedto CHD in the diabetes group than in the non-diabetic group(92.59% versus 79.43%,p<0.0005); theproportion of the population of the patients with CHD not requiring for PCI wasalmost idetical in the two groups(23.30% versus 25.97%, p=0.33); the proportionof the patients with CHD performed the procedure of stent implantation(including thepatients receiving follow-up coronary angiography after stenting) were not differ significantly between the two groups(35.61% versus32.61%, p=0.30); more patients with CHD were proposed to perform the CABG inthe diabetes group than in the non-diabetic group(31.91% versus 17.35%, p<0.0005)(as table 2).


Discussion

 

Coronary heartdisease(CHD)  is the essential cardiacmanifestation of diabetes mellitus type 2 and is responsible for the predominantnumber of deaths[9], it estimate that CHD accounts for70-80% of mortalities in diabetic patients [10]. The clinicalrelevance of these results is documented by an increased incidence ofcardiovascular events, and particularly in the "Framingham study" [11]and in the epidemiological and longitudinal examinations [12,13].The influence of diabetes mellitus is statistically independent of otherestablished risk factors for the manifestation of coronary heart disease and isregarded as the risk factor with the highest predictive value for the incidenceof cardiovascular complications. CHD risk for those with type 2 DM is as greatas that associated with a previous history of myocardial infarction [10,14].Ahigher plaque extent and more calcified lesions were observed in diabeticpatients on MSCT. Type 2 diabetic patients had more extensive atheroscleroticlesion in their coronary arteries than the matched non diabetic control on CAG suggestingan independent effect of diabetic mellitus on atherosclerotic process. However, progressive CHD is asymptomatic in many cases of type 2 DM,which makes it difficult to diagnose at the proper time [15].

The question remains, how does diabetes mediate its specific effectstowards a diabetic specific morphology? Some authors suggest that diabeticsundergo invasive evaluation later than others due to their cardiac neuropathyand the resulting lack of symptoms, others, that the impact of the oftencombined risk factors (e.g. hypertension, high LDL etc.) may trigger anaccelerated form of atherosclerosis. Diabetes increases coronary risk for bothmen and women but diabetes increases the absolute rate of coronary events inwomen by more than in men. The reason for this is not clear, and may relate tobiological differences, differences in treatment, or both [ 12] . A Nationwide Study in England shows diabetes was associatedwith an ~3.5- to 5-fold risk of CVD events compared with non-diabetic patients, aggressive risk reduction is needed to furtherreduce the high absolute and relative risk of CVD still present in people withdiabetes[16].

In this study,1406 consecutive patients were suspected or proven CHD indicated by the non-invasive examinations, ofthese patients, 351 were Type 2 diabetic, 1055 were non diabetic. It shows thatolder age, more female, and more hypertention and unstable agina patients in diabeticgroup than non diabetic group, and that increased morbidityof CHD in diabeticgroup , all the diffences were statistically significant. The results indicate diabeticpatients often have multiple cardiac risk factors and more likely to develop intoCHD (92.59% versus 79.43%, p<0.0005).

With regardto the coronary morphology, Coronary atherosclerosis can be found in moresegments and is generally located more distally by angiography[17],show a higher extent of coronary plaque burden and moreextensive and severer stenosis atherosclerosis in diabetic patients by usingintravascular ultrasound (IVUS) [18-20]. In BARI 2D trial, diabetic patients were assigned to CABG typically being higher risk at baseline,and expecting to have higher event rates; indeed, amongpatients who were assigned to the medical-therapy group in the CABG stratum,the 5-year mortality (16.4%) was much higher than that among patients as signedto medical therapy in the PCI stratum (10.2%)[21]. BARIstudy comparing balloon angioplasty with CABG showed that the initial mortalitydifference between these two groups, favoring CABG, persisted at 10 years. Untillrecent years, the advantage of CABG over PCI remains in patients withleft main coronary artery disease, three-vessel disease, and diffuse CAD; diabetesmellitus (DM) remains the most important one to predict poor early and lateoutcomes even in patients undergoing complete revascularization with CABG[22],but Three yearclinical outcome of ARTS I and ARTS II indicated that diabeteswas the strongest independent predictor of MACCE among PCItreated patients (p<0.02), but didn't affect three-year outcomes following CABG[23]. In our study, there were more patients proposed for CABG in diabetic patients than non-diabetic patients (31.91% versus 17.35%, p<0.0005), the proportion of the population of the patients with CHDnot requiring for PCI and performed the procedure of stent implantation werealmost idetical in the two groups(p=0.33 and p=0.30, respectively). It indicatediabetic patients are prone to a diffuseand rapidly progressive form of atherosclerosis, and more diabetic patients need for CABG.

Several limitations of the study deserve attention. Being asingle-center observational study may be a limitation, the number of cases inthe study was small. oral glucose tolerance test(OGTT) was not performed for screeningdiabetes, so the diabetes might be underdiagnosed in this study population. Thestudy only examined the anatomic demonstration of the lesions in the coronaryarteries by CAG, without the functional examination of such lesions(fractionalflow reserve, FFR) and other anatomic examination measure such as IVUS and opticalcoherence tomography(OCT). Long term clinical outcomes are needed to be furtherstudied in these patients. However, the results show the therapeutic proportionof the patients with type 2 diabetes mellitus undergone CAG in the era ofdevelopment in MSCT in our real clinical practice.

Conclusion: The morbidity rate of coronary heart disease among patientswith type 2 diabetes is greater than non- diabetes, patients withtype 2 diabetes have a significantly higher proportion rate of coronary arterybypass grafting which had been proposed.