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Vol. 7. Núm. H.
Diabetología para cardiólogos
Páginas 42H-48H (Octubre 2007)
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Vol. 7. Núm. H.
Diabetología para cardiólogos
Páginas 42H-48H (Octubre 2007)
Diabetología para cardiólogos
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Revascularización coronaria en el paciente diabético
Coronary Revascularization in Diabetic Patients
Visitas
31
Josep Guindo
Autor para correspondencia
jguindos@hotmail.com

Correspondencia: Dr. J. Guindo. Servicio de Cardiología. Hospital Vall d’Hebron. Passeig de la Vall d’Hebron, 119-129. 08035 Barcelona. España.
, Enric Domingo, Bruno García, Nuria Batalla, Gerard Martí, Mauricio Vanegas, Joan Ángel
Sección de Hemodinámica. Servicio de Cardiología. Hospital Vall d’Hebron. Barcelona. España
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La enfermedad cardiovascular es la principal causa de morbilidad y mortalidad en los pacientes con diabetes mellitus. Se ha demostrado que los pacientes diabéticos presentan una mayor incidencia de enfermedad coronaria multivaso, con mayor frecuencia de lesiones complejas, pobres lechos distales y una progresión de la enfermedad más rápida que la población general no diabética.

La revascularización coronaria percutánea (ICP) ha demostrado su utilidad en los pacientes diabéticos. Sin embargo, aunque los resultados angiográficos iniciales son buenos, hay una mayor incidencia de reestenosis, un riesgo más elevado de complicaciones y una menor supervivencia a largo plazo. Los stents farmacoactivos han reducido notablemente el riesgo de reestenosis y complicaciones tardías.

En espera de los resultados de los estudios actualmente en marcha, en los pacientes diabéticos con enfermedad multivaso, la cirugía de derivación aortocoronaria sigue siendo el tratamiento de primera elección. Sin embargo, hay que destacar que, desde un punto de vista práctico, a la hora de indicar cirugía de derivación aortocoronaria o ICP deberemos basarnos en las características particulares del paciente (p. ej., comorbilidad asociada) y en la experiencia del propio centro, ya que hay notables diferencias en función de la experiencia del equipo quirúrgico y de cardiología intervencionista.

Por último, es muy importante destacar que, en los pacientes diabéticos en los que se realiza revascularización coronaria, con independencia del método utilizado, es de trascendental importancia establecer un tratamiento medico enérgico que incluya modificaciones en el estilo de vida (tabaquismo, síndrome metabólico, etc.), ntiagregación plaquetaria, tratamiento con estatinas en las dosis adecuadas (objetivo terapéutico con un valor de colesterol unido a lipoproteínas de baja densidad<70mg/dl), bloqueadores beta, inhibidores de la enzima de conversion de la angiotensina-inhibidores de los receptores de la angiotensina II, control glicérico-metabólico, etc., ya que en estos pacientes la progresión de la enfermedad es mucho más rápida que en la población no diabética y el riesgo de complicaciones, a pesar de la revascularización, sigue siendo elevado.

Palabra clave:
Angioplastia coronaria
Cirugía de derivación aortocoronaria
Reestenosis
Diabetes mellitus tipo 2
Abreviaturas:
ACTP
IAM
ICP
SCA

Cardiovascular disease is the principle cause of morbidity and mortality in patients with diabetes mellitus. It has been observed that diabetic patients usually present with a higher incidence of coronary artery disease involving multiple vessels, complex lesions, poor distal vascular beds, and more rapid disease progression than does the general nondiabetic population.

Percutaneous coronary revascularization has been shown to be useful in diabetic patients. However, although initial angiographic results are good, there is a high incidence of restenosis, a increased risk of complications, and a low long-term survival rate. Drugeluting stent have markedly reduced the risk of restenosis and late complications.

While the results of ongoing studies are still awaited, bypass surgery remains the treatment of first choice in diabetic patients with multivessel disease. Nevertheless, it is important to remember that, from a practical point of view, the decision on when to carry out bypass surgery or percutaneous coronary intervention must be based on the individual patient's characteristics (e.g., associated comorbid conditions) and on the experience of the center involved. The level of experience of surgical teams and interventional cardiologists varies widely.

Finally, it should be emphasized that the administration of aggressive medical treatment is of paramount importance in diabetic patients who are undergoing coronary revascularization, irrespective of the technique used. Treatment should include lifestyle modification (e.g., for smoking and metabolic syndrome), and, for example, antiplatelet therapy, an adequate statin dose (with the aim of achieving a low-density lipoprotein cholesterol level<70mg/dL), beta-blockers, angiotensinconverting enzyme inhibitors, and angiotensin II receptor antagonists because disease progression is much more rapid in these patients than in the nondiabetic population and the risk of complications remains elevated, despite revascularization.

Key words:
Coronary angioplasty
Coronary bypass surgery
Restenosis
Type-2 diabetes mellitus
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