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Diabetics are at an increased risk of cardiovascular morbidity and mortality as a consequence of inherent metabolic abnormalities and comorbidities. Furthermore, these patients derive less benefit from the standard therapies of coronary artery disease (CAD); the unique pathophysiological response to arterial injury has a profound effect on outcomes of percutaneous coronary interventions (PCIs). However, as the technology, techniques and experience of operators in PCI are evolving, the understanding of revascularisation strategies and patterns of clinical practice are changing. In this review, we discuss specific issues related to cardiac intervention in diabetics.
Magnitude of the problem, pathophysiology and mechanistic insights into adverse outcomes after revascularisation
Currently, diabetes affects >180 million people worldwide. In the current era of advanced medical therapy, improved medical facilities and medical infrastructure, the term myocardial infarction (MI) equivalent might not hold true.1 However, despite improved outcomes, the gradient of increased risk of mortality and morbidity as compared with non-diabetics persists throughout the spectrum of CAD. Diabetics constitutes around one quarter of patients undergoing revascularisation. Both types of revascularisation strategies have been evaluated extensively. Preoperative mortality, repeat revascularisation and long-term mortality are the issues of concern.
Diabetes is a metabolic disorder characterised by chronic hyperglycaemia and insulin resistance. Disturbed delicate balance of fibrinolytic system as well as abnormalities of platelet structure and function results (box 1) in a persistent prothrombotic milieu.2 (A) Metabolic factors: Hyperglycaemia include endothelial dysfunction, vascular effects of advanced glycation end products, adverse effects of circulating free fatty acids and increased systemic inflammation. (B) Vascular anatomic characters: Diabetics have more frequent diffuse disease, higher prevalence of extensive CAD, left main disease, multivessel disease and occlusions. The narrow calibred vessels are associated with impaired collateral development. (C) Adverse prothrombotic milieu and high atherosclerotic burden: Proteofibrinolytic system and platelet biology are unfavourably altered in diabetes and a state of platelet activation exists. Glycoprotein IIb/IIIa (GP …
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