Información del artículo
La diabetes mellitus está presente en casi un tercio de los pacientes que presentan un síndrome coronario agudo y es considerada como un factor de riesgo cardiovascular independiente, que suele asociarse con hipertensión, obesidad y dislipemia. Las alteraciones metabólicas y hematológicas características de los diabéticos favorecen la progresión precoz, severa y rápida de la enfermedad coronaria. La prevención y el tratamiento óptimo del síndrome coronario agudo del diabético sigue siendo un desafío para la cardiología actual. El tratamiento multifactorial agresivo reduce la morbimortalidad de estos pacientes. Los bloqueadores beta y los trombolíticos proporcionan beneficio similar al de los no diabéticos, pero son infrautilizados. La mejor opción de tratamiento revascularizador, sobre todo en la enfermedad multivaso, continúa siendo controvertido. La liberación de stents y el uso de abciximab redujo de forma significativa las complicaciones de la angioplastia. Los injertos arteriales de mamaria mejoran el pronóstico a largo plazo y puede ser la mejor alternativa en la enfermedad multivaso.
Palabras clave:
Hiperglucemia
Diabetes mellitus
Cardiopatía isquémica
Abreviaturas:
AAS
ADMA
ADO
AII
AGL
ASox
BB
CA
CAM
CC
CI
CML
CV
DDAH
DM
ECV
eONs
ET
FIK 3
FT
FvWF
GP
GP IIb/IIIa
HDL
HTA
H4B
IL-6
IM
LDL
LH
LOX-1
LPL
MCP-1
NAD(P)H
NF-κB
NO
PAI-1
PCR
PDGF
PGA
PIC
PKC
PPAR
RAGE
RI
SCA
SCASEST
SOD
SRA
TG
TGF-β1
TNF-α
TRAF3
VEGF
Diabetes mellitus is present in almost one-third of patients with acute coronary syndrome. It is regarded as an independent cardiovascular risk factor that is usually associated with hypertension, obesity and dyslipidemia. The metabolic and hematological abnormalities characteristic of diabetes predispose to the early and rapid progression of severe coronary artery disease. The prevention and optimum treatment of acute coronary syndrome in diabetics provides an ongoing challenge for today's cardiologists. Aggressive combination treatment can reduce morbidity and mortality in these patients. Beta-blockers and thrombolytics have demonstrated benefits similar to those observed in non-diabetic patients, but they are underused. In addition, there is still some controversy about the best approach to revascularization, particularly for multivessel disease. The introduction of stents and the use of abciximab have significantly reduced complications associated with angioplasty. The use of internal mammary artery grafts has improved long-term prognosis and may be the best option for multivessel disease.
Key words:
Hyperglycemia
Diabetes mellitus
Ischemic heart disease
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Bibliografía
[1.]
J. Stamler, O. Vaccaro, J.D. Neaton, D. Wentworth.
Diabetes, other risk factors and 12-year cardiovascular mortality for men screened in the multiple risk factor intervention trial.
Diabetes Care, 16 (1993), pp. 434-444
[2.]
I. González Maqueda.
Hipertensión arterial y diabetes.
Rev Esp Cardiol, 50 (1997), pp. 33-48
[3.]
I. González Maqueda.
El cardiópata diabético. La macroangiopatía diabética. Mecanismos patogénicos. Tratamientos antiisquémicos y metabólicos. Formación Continuada en Cardiología. Sociedad Española de Cardiología.
Masson S.A., (2000),
[4.]
V.H. Thourani, W.S. Weintraub, B. Stein, S.S. Gebhart, J.M. Craver, E.L. Jones, et al.
Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting.
Ann Thorac Surg, 67 (1999), pp. 1045-1052
[5.]
B. Stein, W.S. Weintraub, S.P. Gebhart, C.L. Cohen-Bernstein, R. Grosswald, H.A. Liberman, et al.
Influence of diabetes mellitus on early and late outcome after percutaneous transluminal coronary angioplasty.
Circulation, 91 (1995), pp. 979-989
[6.]
S.M. Haffner, S. Lehto, T. Ronnemaa, K. Pyrola, M. Laaskso.
Mortality from coronary heart disease in subjects with type II diabetes and in nondiabetic subjects with and without prior myocardial infarction.
N Engl J Med, 339 (1998), pp. 229-234
[7.]
J.M. Evans, J. Wang, A.D. Morris.
Comparison of cardiovascular risk between patients with type 2 diabetes and those who had had a myocardial infarction: cross sectional and cohort studies.
BMJ, 324 (2002), pp. 939-943
[8.]
K. Malmberg, S. Yusuf, H.C. Gerstein, J. Brown, F. Zhao, D. Hunt, et al.
Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction. Results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes). Registry.
Circulation, 102 (2000), pp. 1014-1019
[9.]
E. Barrett-Connor, B.A. Conn, D.C. Wingard, S.L. Edelstein.
Why is diabetes mellitus a strong risk factor for fatal ischemic heart disease in women than in men? The Rancho Bernardo Study.
JAMA, 265 (1991), pp. 627-631
[10.]
The DECODE Study Group.
Gender difference in all-cause and cardiovascular mortality related to hyperglycaemia and newlydiagnosed diabetes.
Diabetologia, 46 (2003), pp. 608-617
[11.]
P.A. Lotufo, J.M. Gaziano, C.U. Chae, U.A. Ajani, G. Moreno-John, J.E. Buring, et al.
Diabetes and all-cause and coronary heart disease mortality among US Male Physicians.
Arch Intern Med, 161 (2001), pp. 242-247
[12.]
F.B. Hu, M.J. Stampfer, C.G. Solomon, S. Liu, W.C. Willett, F.E. Speizer, et al.
The impact of diabetes mellitus on mortality from all causes and coronary heart disease in women.
Arch Intern Med, 161 (2001), pp. 1717-1723
[13.]
M.M. Graham, W.A. Ghali, P.D. Faris, P.D. Galbraith, C.M. Norris, M.L. Knudtson, APPROACH Investigators.
Sex differences in the prognostic importance of diabetes in patients with ischemic heart disease undergoing coronary angiography.
Diabetes Care, 26 (2003), pp. 3142
[14.]
R. Huxley, F. Barzi, M. Woodward.
Excess risk of fatal coronary heart disease associated with diabetes in men and women: metaanalysis of 37 prospective cohort studies.
BMJ, 332 (2006), pp. 73-78
[15.]
C.S. Fox, L. Sullivan, R.B. D’Agostino Sr, P.W. Wilson, Framingham Heart Study.
The significant effect of diabetes duration on coronary heart disease mortality: the Framingham Heart Study.
Diabetes Care, 27 (2004), pp. 704-718
[16.]
D. Aguilar, S.D. Solomon, L. Kober, J.L. Rouleau, H. Skali, J.J. McMurray, et al.
Newly diagnosed and previously known diabetes mellitus and 1-year outcomes of acute myocardial infarction: the Valsartan in Acute Myocardial Infarction (VALIANT).
Trial Circulation, 110 (2004), pp. 1572-1578
[17.]
M. Bartnik, L. Rydén, R. Ferrari, K. Malmberrg, K. Pyörälä, M.L. Simoons, on behalf of the Euro Heart Survey Investigators, et al.
The Prevalence of abnormal glucose regulation in patients with coronary artery disease across Europe.
Eur Heart J, 25 (2004), pp. 1880-1890
[18.]
E. Eschwege, J.L. Richard, N. Thibult, P. Ducimetiere, J.M. Warnet, J.R. Claude, et al.
Coronary heart disease mortality in relation with diabetes, blood glucose and plasma insulin levels. The Paris Prospective Study, ten years later.
Horm Metab Res Suppl, 15 (1985), pp. 41-46
[19.]
The DECODE Study Group.
Prediction of the risk of cardiovascular mortality using a score that includes glucose as a risk factor. The DECODE Study.
Diabetología, 47 (2004), pp. 2118-2128
[20.]
I. González-Maqueda.
Mecanismos de la progresión e inestabilización del proceso aterotrombótico en la diabetes.
Rev Esp Cardiol, 4 (2004), pp. 14F-30F
[21.]
I. González-Maqueda.
De la disfunción endotelial a la formación de la placa de ateroma.
Manual de Medicina Preventiva Publicación Oficial de la Sociedad Española de Cardiología. Sección de Cardiopatía Preventiva y Rehabilitación, pp. 25-41
[22.]
M.T. Johnstone, S.J. Creager, K.M. Scales.
Impaired endotheliumdependent vasodilation in patients with insulin-dependent diabetes mellitus.
Circulation, 88 (1993), pp. 2510-2516
[23.]
T. Taguchi, M. Brownlee.
The biochemical mechanisms of diabetic tissue damage.
3.ª ed., pp. 47.1-47.17
[24.]
A. Ceriello.
New insights on oxidative stress and diabetic complications may lead to a «causal» antioxidant therapy.
Diabetes Care, 26 (2003), pp. 1589-1596
[25.]
J.A. Beckman, M.A. Creager, P. Libby.
Diabetes and atherosclerosis. Epidemiology, pathophysiology and management.
JAMA, 287 (2002), pp. 2570-2579
[26.]
J. Klein.
Hyperglycemia and microvascular and macrovascular disease in diabetes.
Diabetes Care, 18 (1995), pp. 256-268
[27.]
R.H. Eckel, M. Wassef, A. Chait, B. Sobel, E. Barrett, G. King, et al.
Prevention Conference VI. Diabetes and cardiovascular disease. Writing Group II: pathogenesis of atherosclerosis in diabetes.
Circulation, 105 (2002), pp. e138-e143
[28.]
P.C. Deedwania.
Diabetes and vascular disease: common links in the emerging epidemic of coronary artery disease.
Am J Cardiol, 91 (2003), pp. 68-71
[29.]
N. Varo, D. Vicent, P. Libby, R. Nuzzo, A.L. Calle-Pascual, M.R. Bernal, et al.
Elevated plasma levels of the atherogenic mediator soluble CD40 ligand in diabetic Patients. A novel target of Thiazolidinediones.
Circulation, 107 (2003), pp. 2664-2669
[30.]
C. Urbich, E. Dernbach, A. Aicher.
CD40 ligand inhibits endothelial cell migration by increasing production of endothelial reactive oxygen species.
Circulation, 106 (2002), pp. 981-986
[31.]
T. Kislinger, N. Tanji, T. Wendt.
RAGE mediates inflammation and enhanced expression of tissue factor in the vasculature of diabetic apolipoprotein E null mice.
Arterioscler Thromb Vasc Biol, 21 (2001), pp. 905-910
[32.]
L. Bucciarelli, T. Wendt, W. Qu.
RAGE blockade stabilizes established atherosclerosis in diabetic apolipoprotein-E-null mice.
Circulation, 106 (2002), pp. 2827-2835
[33.]
F. Cipollone, A. Iezzi, M. Fazia, M. Zuchelli, B. Pini, C.H. Cuccurullo, et al.
The receptor RAGE as a progression factor amplifying arachidonate-dependent inflammatory and proteolytic response in human atherosclerotic plaques. Role of glycemic control.
Circulation, 108 (2003), pp. 1070-1077
[34.]
D.J. Angiolillo, E. Bernardo, C. Ramirez, M.A. Costa, M. Sabate, P. Jimenez-Quevedo, et al.
Insulin therapy is associated with platelet dysfunction in patients with type 2 diabetes mellitus on dual oral antiplatelet treatment.
J Am Coll Cardiol, 48 (2006), pp. 298-304
[35.]
A.I. Vinik, T. Erbas, T.S. Park.
Platelet dysfunction in type 2 diabetes.
Diabetes Care, 24 (2001), pp. 1476-1485
[36.]
R. Assert, G. Scherk, A. Bumbure.
Regulation of protein kinase C by short term hypergiycaemia in human platelets in vivo and in vitro.
Diabetologia, 44 (2001), pp. 188-195
[37.]
M. Levi, T. Van der Poll, H.R. Buller.
Bidirectional relation between inflammation and coagulation.
Circulation, 109 (2004), pp. 2698-2704
[38.]
I. González-Maqueda.
Hipertensión arterial y diabetes.
Rev Esp Cardiol, 50 (1997), pp. 33-48
[39.]
J. Ostergren, P. Sleight, G. Dagenais, K. Danisa, J. Bosch, Y. Qilong, et al.
Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease.
Eur Heart J, 25 (2004), pp. 17-24
[40.]
Heart Outcomes Prevention Evaluation (HOPE) Study Investigators.
Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE Study and MICRO-HOPE substudy.
Lancet, 355 (2000), pp. 253-259
[41.]
UKPDS Group.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
Lancet, 352 (1998), pp. 837-853
[42.]
P. Gaede, P. Vedel, N. Larsen.
Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.
N Engl J Med, 348 (2003), pp. 383-393
[43.]
R. Jiang, M.B. Schulze, T. Li, N. Rifai, M.J. Stampfer, E.B. Rimm, et al.
Non-HDL cholesterol and apolipoprotein B predict cardiovascular disease events among men with type 2 diabetes.
Diabetes Care, 27 (2004), pp. 1991-1997
[44.]
R. Sigal, J. Malcolm, A. Arnaout.
Prevention of cardiovascular events in diabetes.
Clin Evid, 15 (2006), pp. 623-645
[45.]
Heart Protection Study investigators.
MRC/BHF Heart Protection Study of colesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placed controlled trial.
Lancet, 361 (2003), pp. 2005-2016
[46.]
CARDS investigators.
Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomized placebo-controlled trial.
Lancet, 364 (2004), pp. 685-696
[47.]
L. Hansson, A. Zanchetti, S.G. Carruthers, B. Dahlöf, D. Elmfeldt, S. Julius, et al.
Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group.
Lancet, 351 (1998), pp. 1755-1762
[48.]
A.V. Chobanian, G.L. Bakris, H.R. Black, W.C. Cushman, L.A. Green, J.L. Izzo, et al.
The seventh report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure. The JNC report.
JAMA, 289 (2003), pp. 2560-2572
[49.]
2003 European Society of Hypertension-European Society of Cardiology Guidelines for the Management of Arterial Hypertension.
J Hypertens, 21 (2003), pp. 1011-1053
[50.]
G.L. Bakris, E. Gaxiola, F.H. Messerli, G. Mancia, S. Erdine, R. Cooper-DeHoff, INVEST Investigators, et al.
Clinical outcomes in the diabetes cohort of the INternational VErapamil SR-Trandolapril study.
Hypertension, 44 (2004), pp. 637-642
[51.]
The Heart Outcomes Prevention Evaluation Study Investigator.
Effects of an Angiotensine-Converting enzyme inhibitor, Ramipril, on cardiovascular events in high-risk patients.
N Engl J Med, 342 (2000), pp. 145-153
[52.]
L. Hansson, L.H. Lindholm, L. Nistaken, J. Lanke, T. Hedner, A. Niklason, et al.
Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project (CAPPP) randomised trial.
Lancet, 353 (1999), pp. 611-616
[53.]
D. Dahlöf, R.B. Devereux, S.E. Kjeldsen, S. Julius, G. Beevers, U. de Faire, et al.
Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol.
Lancet, 359 (2002), pp. 995-1003
[54.]
H. Lithel, L. Hansson, I. Skoog, D. Elmfeldt, A. Hofman, B. Olofsson, for the SCOPE Study Group, et al.
The study on cognition and prognosis in the elderly (SCOPE): principal results of a randomized double-blind intervention trial.
J Hypertens, 21 (2003), pp. 875-886
[55.]
M.J. Brown, C.R. Palmer, A. Castaigne, P.W. De Leeuw, G. Mancia, T. Rosenthal, et al.
Morbidity and mortality in patients randomized to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the International Nifedipine GITS study: Intervention as a Goal in Hypertension Treatment (INSIGHT).
Lancet, 356 (2000), pp. 366-372
[56.]
R.O. Estacio, B.W. Jeffers, N. Gifford, R.W. Schrier.
Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes.
Diabetes Care, 23 (2000), pp. B54-B64
[57.]
R.A. Kronmal, J.I. Barzilay, N.L. Smith, B.M. Psaty, L.H. Kuller, G.L. Burke, et al.
Mortality in pharmacologically treated older adults with diabetes: the Cardiovascular Health Study, 1989-2001.
PLoS Med, 3 (2006), pp. e400
[58.]
K. Maimberg, L. Ryden, S. Efendic.
Randomized trial of insulinglucose infusión followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year.
J Am Coll Cardiol, 26 (1995), pp. 57-65
[59.]
K. Malmberg, L. Ryden, H. Wedel, K. Birkeland, A. Bootsma, K. Dickstein, et al.
Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity.
Eur Heart J, 26 (2005), pp. 650-661
[60.]
S.S. Gottlieb, R.J. McCarter, R.A. Vogel.
Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction.
N Engl J Med, 339 (1998), pp. 489-497
[61.]
C.G. McDonald, S.R. Majumdar, J.L. Mahon, J.A. Johnson.
The effectiveness of beta-blockers after myocardial infarction in patients with type 2 diabetes.
Diabetes Care, 28 (2005), pp. 2113-2117
[62.]
L. Hansson, T. Hedner, P. Lund-Johansen, S.E. Kjeldsen, L.H. Lindholm, J.O. Syvertsen, et al.
Randomised trial of effects of calcium antagonists compared with diuretics and beta-blockers on cardiovascular morbidity and mortality in hypertension: the Nordic Diltiazem (NORDIL) Study.
Lancet, 356 (2000), pp. 359-365
[63.]
R.O. Estacio, B.W. Jeffers, W.R. Hiatt, S.L. Biggerstaff, N. Gifford, R.W. Schrier.
The effect of nisoldipine as compared with Enalapril on cardiovascular outcomes in patients with non-insuline-dependent diabetes and hypertension.
N Engl J Med, 338 (1998), pp. 645-654
[64.]
A. Abizaid, R. Kornowski, G.S. Mintz, M.K. Hong, A.S. Abizaid, R. Mehran, et al.
The influence of diabetes mellitus on acute and late clinical outcomes following coronary stent implantation.
J Am Coll Cardiol, 32 (1998), pp. 584-589
[65.]
D. Aronson, Z. Bloomgarden, E.J. Rayfield.
Potential mechanisms promoting restenosis in diabetic patients.
J Am Coll Cardiol, 27 (1996), pp. 528-535
[66.]
A. Abizaid, M.A. Costa, M. Centemero, A.S. Abizaid, V.M.G. Legrand, R.V. Limet, et al.
Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients. Insight from the Arterial Revascularization Therapy Study (ARTS) Trial.
Circulation, 104 (2001), pp. 553-638
[67.]
V. Mathew, B.J. Gersh, M.B.C.h.B. Dphil, B.A. Williams, W.K. Laskey, J.T. Willerson, et al.
Outcomes in patients with diabetes mellitus undergoing percutaneous coronary intervention in the current era. A report from the prevention of restenosis with Tranilast and its outcomes (PRESTO) trial.
Circulation, 109 (2004), pp. 476-480
[68.]
Y. Honda, P.J. Fitzgerald.
Stent trombosis. An issue revisited in a changing world.
Circulation, 108 (2003), pp. 2-5
[69.]
D.L. Bhatt, S.P. Marso, M. Lincoff, K.E. Wolski, S.G. Ellis, E.J. Topol.
Abciximab reduces mortality in diabetics following percutaneous coronary intervention.
J Am Coll Cardiol, 35 (2000), pp. 922-928
[70.]
S.P. Marso, M. Lincoff, S.G. Ellis, D.L. Bhatt, J.-F. Tanguay, N.S. Kleiman, et al.
Optimizing the percutaneous interventional outcomes for patients with diabetes mellitus. Results of the EPISTENT (Evaluation of Platelet IIb/IIIa Inhibitor for Stenting Trial) Diabetic Substudy.
Circulation, 100 (1999), pp. 2477-2484
[71.]
The ERASER Investigators.
Acute platelet inhibition with abciximab does not reduce in-stent restenosis (ERASER Study).
Circulation, 100 (1999), pp. 799-806
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