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
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Bibliografía
[1.]
R.W. Nesto.
Diabetes and the heart disease.
Braunwald's heart disease, Elsevier Saunders, pp. 1355-1366
[2.]
L. Rydén, E. Standl, M. Bartnik, G. Van den Berghe, J. Betteridge, M. Jan de Boer, et al.
Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary,. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD).
Eur Heart J, (2007), 28 pp. 88-136
[3.]
M. Laakso.
Hyperglycaemia: cardiovascular disease in type 2 diabetes.
Diabetes, (1999), 48 pp. 937-942
[4.]
K. Franklin, R.J. Goldberg, F. Spencer, W. Klein, A. Budaj, D. Brieger, GRACE Investigators. Implications of diabetes in patients with acute coronary syndromes, et al.
The Global Registry of Acute Coronary Events.
Arch Intern Med, (2004), 164 pp. 1457-1463
[5.]
D. Hasdai, S. Behar, L. Wallentin, N. Danchin, A.K. Gitt, E. Boersma, et al.
A prospective survey on the characteristic, treatments and outcomes of patients with acute coronary syndromes in Europe and Mediterranean basin. The Euro Heart Survey of Acute Coronary Syndromes.
Eur Heart J, (2002), 23 pp. 1190-1201
[6.]
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, (2002), 102 pp. 1014-1019
[7.]
M. Bartnik, L. Rydén, R. Ferrari, K. Malmberg, 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, (2004), 25 pp. 1880-1890
[8.]
T. Hammoud, J.F. Tanguay, M.G. Bourassa.
Management of coronary artery disease: therapeutic options in patients with diabetes.
J Am Coll Cardiol, (2000), 36 pp. 355-365
[9.]
W. Otter, S. Kleybrink, W. Doering, E. Standl, O. Schnel.
Hospital outcome of acute myocardial infarction in patients with and without diabetes mellitus.
Diabet Med, (2004), 21 pp. 183-187
[10.]
K.H. Mak, D.J. Moliterno, C.B. Granger, D.P. Miller, H.D. White, R.G. Wilcox, for the GUSTO-I Investigators, et al.
Influence of diabetes mellitus on clinical outcome in the thrombolytic era of acute myocardial infarction.
J Am Coll Cardiol, (1997), 30 pp. 171-179
[11.]
K.A. Eagle, R.A. Guyton, R. Davidoff, F.H. Edwards, G.A. Ewy, T.J. Gardner, et al.
ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery).
Circulation, (2004), 110 pp. e340
[12.]
S.C. Smith Jr, T.E. Feldman, J.W. Hirshfeld Jr, A.K. Jaccobs, M.J. Kern, S.B. King, et al.
ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention).
J Am Coll Cardiol, (2006), 47 pp. e1
[13.]
S. Silber, P. Albertsson, F.F. Aviles, P.C. Camici, A. Colombo, C. Hamm, et al.
Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology.
Eur Heart J, (2005), 26 pp. 804-847
[14.]
P.R. Soares, W.A. Hueb, P.A. Lemos, N. Lopez, E.E. Martinez, L.A. César, et al.
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, (2006), 114 pp. I420-I424
[15.]
T. Przewlocki, P. Pieniazek, W. Ryniewicz, M. Kostkiewicz, M. Olszowska, P. Podolec, et al.
Long -term outcome of coronary balloon angioplasty in diabetic patients.
Int J Cardiol, (2000), 76 pp. 7-16
[16.]
K.H. Mak, D.P. Faxon.
Clinical studies on coronary revascularization in patients with type 2 diabetes.
Eur Heart J, (2003), 24 pp. 1087-1103
[17.]
B. Stein, W.S. Weintraub, S.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, (1995), 91 pp. 979-989
[18.]
K.E. Kip, D.P. Faxon, K.M. Detre, W. Yeh, S.F. Kelsey, J.W. Currier.
Coronary angioplasty in diabetic patients. The National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry.
Circulation, (1996), 94 pp. 1818-1825
[19.]
E. Van Belle, K. Abolmaali, C. Bauters, J.C. Bodart, K. Abolmaali, T. Meurice, et al.
Restenosis, late vessel occlusion and left ventricular function six months after balloon angioplasty in diabetic patients.
J Am Coll Cardiol, (1999), 34 pp. 476-485
[20.]
Y. Rozenman, D. Sapoznikov, M. Mosseri, D. Gilon, C. Lotan, H. Nassar, et al.
Long-term angiographic follow-up of coronary balloon angioplasty in patients with diabetes mellitus. A clue to the explanation of the results of the BARI study.
J Am Coll Cardiol, (1997), 30 pp. 1420-1425
[21.]
Y. Otsuka, S. Myazaki, H. Okumura, S. Yasuda, S. Daikoku, I. Morii, et al.
Abnormal glucose tolerance, not small vessel diameter, is a determinant of long-term prognosis in patients treated with balloon coronary angioplasty.
Eur Heart J, (2000), 21 pp. 1790-1796
[22.]
E. Van Belle, C. Bauters, E. Hubert, J.C. Bodart, K. Abolmaali, T. Meurice, et al.
Restenosis rates in diabetic patients. A comparison of coronary stenting and balloon angioplasty in native coronary vessels.
Circulation, (1997), 96 pp. 1454-1460
[23.]
J. Mehilli, A. Kastrati, J. Dirschinger, F. Dotzer, J. Pache, J. Hausleiter, et al.
Comparison of stenting with balloon angioplasty for lesions of small coronary vessels in patients with diabetes mellitus.
Am J Med, (2002), 112 pp. 13-18
[24.]
E. Van Belle, M. Périé, D. Braune, A. Chmait, T. Meurice, K. Abolmaali, et al.
Effects of coronary stenting on vessel patency and long-term clinical outcome after percutaneous coronary revascularization in diabetic patients.
J Am Coll Cardiol, (2002), 40 pp. 410-417
[25.]
N.E. West, P.N. Ruygrok, C.M. Disco, M.W. Webster, W.K. Lindeboom, W.W. O’Neill, et al.
Clinical and angiographic predictors of restenosis after stent deployment in diabetic patients.
Circulation, (2004), 109 pp. 867-873
[26.]
I. Moussa, M.B. Leon, D.S. Baim, W.W. Oneill, J.J. Pompa, M. Buchbinder, et al.
Impact of sirolimus-eluting stents on outcome in diabetic patients: a SIRIUS (SIRolimUS-coated Bx Velocity balloon-expandable stent in the treatment of patients with de novo coronary artery lesions) substudy.
Circulation, (2004), 109 pp. 2273-2278
[27.]
J.B. Hermiller, A. Raizner, L. Cannon, P.A. Gurbel, M.A. Kutcher, S.C. Wong, et al.
Outcomes with the polymer-based paclitaxel-eluting TAXUS stent in patients with diabetes mellitus: the TAXUSIV trial.
J Am Coll Cardiol, (2005), 45 pp. 1172-1179
[28.]
M. Sabate, P. Jimenez-Quevedo, D.J. Angiolillo, J.A. Gomez-Hospital, F. Alfonso.
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, (2005), 112 pp. 2175-2183
[29.]
A. Dibra, A. Kastrati, J. Mehilli, J. Pache, H. Schuhlen, N. Von Beckerath, et al.
Paclitaxel-eluting or sirolimus-eluting stents to prevent restenosis in diabetic patients.
N Engl J Med, (2005), 353 pp. 663-670
[30.]
J. Daemen, H.M. García-García, N. Kukreja, F. Imani, P.P. De Jaegere, G. Sianos, et al.
The long-term value of sirolimus- and placlitaxel-eluting stent over bare metal stents in patients with diabetes mellitus.
Eur Heart J, (2007), 28 pp. 26-32
[31.]
G.W. Stone, J.W. Moses, S.G. Ellis, J. Schofer, K.D. Dawkins, M.C. Morice, et al.
Safety and efficacy od sirolimus- and placlitaxel-eluting coronary stents.
N Engl J Med, (2007), 356 pp. 998-1008
[32.]
A. Kastrati, J. Mehilli, H. Schuhlen, S. Martinoff, J. Pache, H. Schuhlen, et al.
A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel.
N Engl J Med, (2004), 350 pp. 232-238
[33.]
J.C. O'Shea, C.E. Buller, W.J. Cantor, A.B. Chandler, E.A. Cohen, D.J. Cohen, for the ESPRIT Investigators, et al.
Long-term efficacy of platelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention.
JAMA, (2002), 287 pp. 618-621
[34.]
D.L. Bhatt, S.P. Marso, A.M. Lincoff, K.E. Wolski, S.G. Ellis, E.J. Topol.
Abciximab reduces mortality in diabetics following percutaneous coronary intervention.
J Am Coll Cardiol, (2000), 35 pp. 922-928
[35.]
M. Roffi, D.P. Chew, D. Mukherjee, D.L. Bhatt, J.A. White, C. Heeschen, et al.
Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes.
Circulation, (2001), 104 pp. 2767-2771
[36.]
N. Salomon, U. Page, J. Okies, J. Stephens, A.H. Krause, J.C. Bigelow.
Diabetes mellitus and coronary artery bypass.
J Thorac Cardiovasc Surg, (1983), 85 pp. 264-271
[37.]
T. Higgins, F. Estafanous, F. Loop, G.J. Beck, J.M. Blum, L. Paranandi.
Stratification of morbidity and mortality outcome of preoperative risk factors in coronary artery bypass patients.
JAMA, (1992), 267 pp. 2344-2348
[38.]
W. Whang, J.T. Bigger Jr.
Diabetes and outcomes of coronary artery bypass graft surgery in patients with severe left ventricular dysfunction: results from The CABG Patch Trial database. The CABG Patch Trial Investigators and Coordinators.
J Am Coll Cardiol, (2000), 36 pp. 1166-1172
[39.]
C. Rajakaruna, C.A. Rogers, C. Suranimala, G.D. Angelini, R. Ascione.
The effect of diabetes mellitus on patients undergoing coronary surgery: a risk-adjusted analysis.
J Thorac Cardiovasc Surg, (2006), 132 pp. 802-810
[40.]
S.B. King, G. Dangas, J.W. Moses.
Is surgery preferred for the diabetic with multivessel dissease?.
Circulation, (2005), 112 pp. 1500-1515
[41.]
The BARI 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, (1997), 96 pp. 1761-1769
[42.]
M.G. Bourassa, K.E. Kip, A.K. Jacobs, R.H. Jones, G. Sopko, A.D. Rosen, et al.
Is a strategy of intended incomplete percutaneous transluminal coronary angioplasty revascularization acceptable in nondiabetic patients who are candidates for coronary artery bypass graft surgery? The Bypass Angioplasty Investigation (BARI).
J Am Coll Cardiol, (1999), 33 pp. 1627-1636
[43.]
A. Abizaid, M.A. Costa, M. Centemero, A.S. Abizaid, V.M. Legrand, R.V. Limet, 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, (2001), 104 pp. 533-538
[44.]
P.W. Serruys, F. Unger, J.E. Sousa, A. Jatene, H.J. Bonnier, J.P. Schonberger, et al.
Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease.
N Engl J Med, (2001), 344 pp. 1117-1124
[45.]
A. Rodríguez, V. Bernardi, J. Navia, J. Baldi, L. Grinfield, J. Martinez, et al.
Argentine randomized study: coronary angioplasty with stenting versus coronary artery bypass surgery in patients with multi-vessel disease (ERACI II): 30-day and one-year follow-up results.
J Am Coll Cardiol, (2001), 37 pp. 51-58
[46.]
The SoS Investigators.
Coronary artery bypass surgery versus percutaneous coronary intervention with stent implantation in patients with multivessel coronary artery disease (the Stent or Surgery trial): a randomised controlled trial.
Lancet, (2002), 360 pp. 965-970
[47.]
K. Fox, M.A. Alonso-Garcia, D. Ardissimo, P. Buszman, P.G. Camici, F. Crea, et al.
Guidelines on the management of angina pectoris. The Task Force on the management of the stable angina pectoris of the European Society of Cardiology.
Eur Heart J, (2006), 27 pp. 1341-1381
[48.]
Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina. Disponible en: www.acc.org/qualityandscience/clinical/statements.htm
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