1. Coronary Revascularisation in Patients With Diabetes Mellitus Dr Rod Stables The Cardiothoracic Centre Liverpool UK

2. Introduction Patients with diabetes mellitus Increased incidence of CAD More extensive disease at angiography Worse prognosis than non-diabetic CAD >20% of all revascularisation procedures

3. Revascularisation in Diabetes Mellitus Heartwire (www.theheart.org) Nov 1999 “Despite stents, diabetic patients undergoing PCI still face higher death rates.” AHA Scientific Statement 1999 “Recent studies indicate that coronary angioplasty is less efficacious for patients with diabetes than for those without; these reports further reveal that CABG is the preferred therapy in patients with diabetes when invasive management is required.”

4. PCI in Patients With Diabetes Mellitus Registry reports - PCI outcomes in diabetics Procedural success rates comparable Less favourable medium term outcomes Death and non-fatal MI Progressive heart failure Repeat revascularisation ‘New disease’ - progression Increased restenosis rates

5. The Nature of Restenosis in Diabetics Van Belle et al Circulation 2001;103:1218-24 604 patients - Balloon angioplasty only Repeat angiography at 6 months (n = 513) Clinical follow-up at 10 year (n = 603) Increased restenosis rates Non-occlusive restenosis 50% Occlusive restenosis 18% Occlusion associated with mortality Hazard ratio 2.16 (1.43 - 3.26)

6. PCI With Stents in Diabetics Elezi et al J Am Coll Cardiol 1998;32:1866-73 Stent implantation 715 DM 2839 Non-DM Angiography 6 months Restenosis 37.5% v 28.3% p<0.001 Target vessel occlusion 5.3% v 3.4% Clinical Follow-up 1 year Event free 73.1% v 78.5% p <0.001 MI rate 10.1% v 5.6% p<0.001

7. PCI v CABG in Patients With Diabetes Randomised trials - subgroup analyses Large scale registry studies

8. PCI v CABG Trials - DM Subgroup Analyses BARI trial - balloon angioplasty era 5 year survival - 81% v 66%

9. PCI v CABG Trials - DM Subgroup Analyses ARTS trial - stent era 1205 patients - DM 208 (17%) CABG PCI 1 year mortality 3.1% 6.3% 1 year repeat revasc 12.4% 21.6% 3 year event free 81.3% 52.7%

10. PCI v CABG - Registry Studies Support BARI / ARTS findings Northern New England Collaborative J Am Coll Cardiol 2001;37:1008 -15 NHLBI Dynamic Registry 1997 / 8 Weintraub et al J Am Coll Cardiol 1998;31:10 - 19

11. CABG in Patients with Diabetes CABG advantage depends on use of LIMA  rates of procedure related morbidity Renal failure Wound infection Sternal wound failure Possible increased stroke risk ARTS trial - 1 year CVA rate CABG 6.3% PCI 1.8%

12. A Future for PCI Revascularisation in Diabetics ? BARI registry 5 year follow up Patients screened and Tx but not randomised Death rates CABG 14.9% PCI 14.4% SoS Trial - Diabetes subgroup

13. SoS Subgroup Analysis - Diabetes PCI Surgery Diabetics (n) 68/488 74/500 Death/MI in Diabetics 10%11% Death/MI - Others 9.0%9.0%

14. A Future for PCI Revascularisation in Diabetics ? Improved case selection Angiographic patterns of disease BARI CABG advantage only if  4 lesions ? Complete revascularisation CABG advantage  with insulin Tx diabetics Proteinuria as a risk marker Observational data Presence doubles risk of death

15. A Future for PCI Revascularisation in Diabetics ? New therapeutic options Statins Other drugs - ACE inhibitors Drug eluting stents Gp IIb/IIIa antagonists Abciximab

16. EPISTENT Trial - 1 Year Outcomes - Diabetics

17. EPIC EPILOG EPISTENT - Pooled Mortality

18. Conclusions Important therapeutic question Current evidence not definitive Favours CABG revascularisation Widespread / diffuse disease Insulin treated diabetics Microvascular disease PCI case selection New drug agents and technologies A new trial ?

19. Questions and Discussion