(Circulation. 2001;103:1218.)
© 2001 American Heart Association, Inc.
Clinical Investigation and Reports |
Patency of Percutaneous Transluminal Coronary Angioplasty Sites at 6-Month Angiographic Follow-Up
A Key Determinant of Survival in Diabetics After Coronary Balloon Angioplasty
From the Cardiology department, University of Lille, Lille, France.
Correspondence to Eric Van Belle, Service de Cardiologie B, Hôpital Cardiologique, 59037 Lille, France. E-mail ericvanbelle{at}aol.com
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Abstract |
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Background—Several reports have demonstrated a high mortality rate in diabetic patients treated by standard coronary balloon angioplasty. No clear explanation has been provided for this finding.
Methods and Results—Consecutive diabetic patients successfully treated by standard coronary balloon angioplasty (n=604) were enrolled in a follow-up program including repeated angiography at 6 months and long-term clinical follow-up. Clinical follow-up was available in 603 patients (99.8%). Twelve patients died, 2 underwent bypass surgery before scheduled repeated angiography, and 76 declined angiography. Determinants of long-term mortality were analyzed in the 513 patients with angiography at 6 months and long-term clinical follow-up (mean follow-up, 6.5±2.4 years). On the basis of the results of repeated angiography, 3 groups of patients were defined: group 1, 162 patients without restenosis (32%); group 2, 257 patients with nonocclusive restenosis (50%); and group 3, 94 patients with coronary occlusion (18%). Overall actuarial 10-year mortality rate was 36%. Actuarial 10-year mortality was 24% in group 1, 35% in group 2, and 59% in group 3 (P<0.0001). Multivariate analysis demonstrated that coronary occlusion was a strong and independent correlate of long-term total mortality (hazard ratio, 2.16; 95% CI, 1.43 to 3.26; P=0.0003) and cardiac mortality (hazard ratio, 2.38; 95% CI, 1.48 to 3.85; P=0.0004).
Conclusions—This study demonstrates that restenosis, especially in its occlusive form, is a major determinant of long-term mortality in diabetic patients after coronary balloon angioplasty.
Key Words: diabetes mellitus • survival • coronary disease • angioplasty • balloon
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Diabetes, a major risk factor for atherosclerosis and cardiac death, is a an increasing public health problem in western countries1 ; indeed, diabetics represent 15% to 25% of patients referred for percutaneous or surgical treatment of coronary artery disease.2 3 4 5
Percutaneous coronary revascularization (PCR) has gained acceptance as an alternative to CABG in selected patients. However, several reports that demonstrated poor long-term survival in diabetic patients treated by standard coronary balloon angioplasty2 3 6 7 8 have led to concerns regarding the use of PCR in this group of patients.9 10 It is of critical importance in the management of diabetic patients for physicians to understand the reason(s) for their poor outcome after PTCA. Although several hypotheses have been advanced,9 10 11 12 there is still no conclusive explanation for this unexpected "diabetes-PTCA" interaction.
We recently demonstrated that restenosis after standard
coronary balloon angioplasty, the PTCA technique used in the
above-mentioned
studies,2 3 6 7 8
not only was a frequent event in this population but also had a unique
expression in that coronary occlusion (TIMI flow=0 or 1) was observed
in 
14% of
lesions4 13
compared with 3% in nondiabetic
patients.13 From this
observation, we hypothesized that restenosis might be one of the
determinants of the poor outcome of diabetic patients after
PTCA.
We report here the outcome of 637 consecutive diabetic patients included at the time of their first procedure and treated by standard balloon angioplasty. The determinants of long-term mortality, including the status of treated vessels at 6 months, were analyzed in this population.
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Methods |
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Study Population and Follow-Up
Between January 1987 and December 1995, all consecutive patients with successful PTCA in our institution were enrolled in a follow-up program. We report here the outcome of 637 consecutive diabetic patients from the time of their first procedure in our institution during this period and treated by standard balloon angioplasty without adjunctive stent implantation. Patients undergoing primary or rescue balloon angioplasty for acute myocardial infarction (MI) were not included.
At the time of the procedure, patients were asked to return for follow-up angiography at 6 months regardless of symptomatic status. Angiography was performed earlier if clinically indicated.
Long-term clinical follow-up was accomplished by a questionnaire completed by the patient or by telephone contact. Review of hospital records and contact with the referring physician enabled us to complete some missing information. Finally, patients’ municipal records were checked for mortality status. The cause of death was recorded; sudden deaths or deaths of unknown cause were classified as cardiac deaths.
Patient Definitions
At the time of the procedure, patients were
classified as diabetic if they were treated by oral hypoglycemic drugs
or insulin or if they had a history of elevated (
140 mg/dL) fasting
blood glucose on 2 separate occasions in conjunction with ongoing
dietary measures. They were classified into 3 categories—(1) diet
alone, (2) oral hypoglycemic drugs (diet and oral hypoglycemic drugs
but no insulin), and (3) insulin (regardless of other therapy)—at the
time of the initial procedure. In patients treated with oral
hypoglycemic drugs, the use of sulfonylureas was recorded.
Baseline blood glucose and creatinine levels, as well as the presence of end-organ damage (retinopathy, nephropathy, neuropathy) as documented in the medical records, were recorded. Clinical status was recorded at the time of the initial procedure and at angiographic follow-up.
Angioplasty Procedure
Balloon angioplasty without adjunctive stent
implantation was performed according to the standard technique in our
laboratory.4 A vascular
segment was considered successfully treated when the residual luminal
narrowing in the dilated segment immediately after angioplasty was
<50%. The procedure was considered successful when 1 vascular
segment was successfully treated and when no major complication (ECG or
enzymatic evidence of MI, the need for bypass surgery during
hospitalization, or in-hospital death) occurred.
Angiographic Analyses
Quantitative computer-assisted angiographic
measurements were performed as previously described on end-diastolic
frames of angiograms performed at maximal dilatation with the
Computer-Assisted Evaluation of Stenosis and Restenosis
system.4 The anterograde
blood flow was graded with the classification of the TIMI study
group.14 Restenosis was
defined as a >50% diameter stenosis at follow-up, and complete vessel
occlusion was defined as a TIMI grade flow <2.
Patients were considered to have restenosis if 1 of the
successfully dilated lesion(s) had restenosis at follow-up and to have
coronary occlusion if 1 of the successfully dilated lesion(s) had
restenosis and TIMI flow <2 at follow-up angiography. The presence of
new occlusion(s) (TIMI flow <2) at nontreated sites was also recorded.
Left ventricular ejection fraction (LVEF) was calculated on
ventriculograms obtained before angioplasty and at
follow-up.
Statistical Analysis
Data are presented as mean±SD. Comparisons between
groups for continuous data were made with paired or unpaired Student’s
t test or ANOVA followed by
Scheffé’s F test as appropriate. Differences between proportions
were assessed by 
2 analysis.
Late survival was estimated with the Kaplan-Meier method. Differences were tested with a log-rank test. Multivariate correlates of survival were analyzed with Cox’s proportional-hazard model. For verification purposes, variables obtained by Cox analysis were entered into logistic models designed to predict mortality at 5 years, and concordance indexes were calculated. A 2-sided value of P<0.05 was considered to indicate statistical difference. Analyses were performed with SAS software (version 6.12, SAS Institute).
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Results |
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Patients Characteristics and Follow-Up
PTCA was successful in 604 of the 637 patients (95%). Clinical follow-up was available in 603 of the 604 patients (99.8%). Of the 604 patients with successful PTCA, 12 had died at 6 months, and 2 underwent CABG without repeated coronary angiography. Of the remaining 590 patients, 514 (87%) underwent repeated angiography at a mean of 6.7±2.6 months after PTCA. Seventy-six patients declined angiography. One patient was lost to follow-up after repeated angiography. There were no differences in baseline characteristics between patients who were and who were not restudied. We present the results of the 513 patients with 6-month repeated angiography and clinical follow-up.
In the 513 patients, 426 (63%) of the 680 successfully treated lesions had a diameter stenosis >50% at repeated angiography, including 99 lesions (14%) that had occluded (TIMI flow <2). On the basis of these results, 3 groups of patients were defined: group 1, 162 patients without restenosis (32%); group 2, 257 patients with nonocclusive restenosis (50%); and group 3, 94 patients with coronary occlusion (18%). Occlusion at an untreated site occurred in 18 patients (3%).
Baseline study population characteristics are shown in
Table 1
. As expected, restenosis, both occlusive and
nonocclusive, was more frequently observed in patients who underwent
multisite PTCA (P=0.0001).
Patients with end-organ damage had a higher risk of restenosis
(P<0.05), whereas patients
treated with insulin or those with a recent MI had a higher risk of
coronary occlusion at target sites
(P<0.05).
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Changes in LVEF and Clinical Status at
Follow-Up Angiography
Changes in LVEF are reported in
Table 2. There were no differences in LVEF among groups
before PTCA. During follow-up, there was a decrease in LVEF in patients
with occlusion at follow-up angiography, whereas no significant change
was observed in the other 2 groups. These changes resulted in a
significantly lower LVEF at follow-up angiography in the group of
patients with occlusion compared with the other 2 groups.
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The clinical status of patients at follow-up angiography is
presented in
Table 2
. Although patients with nonocclusive or occlusive
restenosis were more likely to have angina than patients without
restenosis (P<0.0001), 30% to
35% of patients with restenosis had no recurrence of angina at
follow-up angiography. In addition, <40% of patients with coronary
occlusion had clinical and/or ECG evidence of unstable angina or acute
MI. Among these patients, 8 had a documented Q-wave MI, 10 had a
documented non–Q-wave MI, and 19 were classified as having unstable
angina. The onset of the ischemic episode was documented within the
first 2 months in 12 patients, between months 2 and 4 in 13 patients,
and after month 4 in 12 patients. Clinically driven repeated
angiography within 4 months of the initial procedure was performed in
22 of 94 patients (23%) with coronary occlusion.
Long-Term Clinical Follow-Up
Long-term clinical follow-up was obtained in the 513
patients a mean of 6.5±2.4 years after follow-up angiography (7.0±2.4
years after the initial PTCA). One hundred thirty-six patients (27%)
died during follow-up. This rate was similar to the rate observed in
the 76 patients with initially successful procedures who did not
undergo repeated angiography (20 deaths; 26%). The
Figure
shows the Kaplan-Meier survival curves as a function of late vessel
patency documented at repeated angiography. At the end of follow-up,
there were 28 deaths among the 162 patients without restenosis (17%),
66 deaths among the 257 patients with nonocclusive restenosis (26%),
and 42 deaths among the 94 patients with coronary occlusion (45%;
P<0.0001). Actuarial 5- and
10-year mortality rates were 13% and 24% in patients without
restenosis, 23% and 35% in patients with nonocclusive restenosis, and
38% and 59% in patients with coronary occlusion
(P<0.0001; the
Figure,
top). Actuarial 5- and 10-year cardiac mortality rates were 10% and
17% in patients without restenosis, 18% and 27% in patients with
nonocclusive restenosis, and 31% and 51% in patients with coronary
occlusion (P<0.0001; the
Figure,
bottom).
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When imbalances in baseline characteristics were controlled for by a Cox’s proportional-hazard model, the hazard ratios (HRs) for nonocclusive restenosis versus no restenosis were 1.63 (95% CI, 1.05 to 2.55; P=0.03) for total mortality and 1.72 (95% CI, 1.01 to 2.87; P=0.04) for cardiac mortality, and the HRs for coronary occlusion versus no restenosis were 3.12 (95% CI, 1.90 to 5.13; P=0.0001) for total mortality and 3.40 (95% CI, 1.93 to 5.99; P=0.0001) for cardiac mortality.
Univariate predictors of long-term mortality among
characteristics at baseline and at follow-up angiography are listed in
Table 3. Multivariate analysis including variables at
baseline and at follow-up angiography showed that occlusive but not
nonocclusive restenosis was an independent predictor of long-term
mortality
(Table 4). Six variables were independently associated with
total mortality: coronary occlusion, age at initial procedure, decrease
in LVEF, end-organ damage, a lower LVEF at baseline, and hypertension
(Table 4). Eight variables were independently associated
with cardiac mortality: coronary occlusion, decrease in LVEF, end-organ
damage, age at initial procedure, multivessel coronary disease, a lower
LVEF at baseline, hypertension, and the occurrence of an occlusion at
an untreated site
(Table 4). When variables obtained by Cox analysis were
entered into logistic regression models designed to determine 5-year
total and cardiac mortality, concordance indexes for the 2 models were
0.736 and 0.758, respectively. After exclusion of patients with a
recent (<1 month) MI at baseline, coronary occlusion remained an
independent predictor of total (HR, 1.88; 95% CI, 1.16 to 3.09;
P=0.01) and cardiac mortality
(HR, 2.33; 95% CI, 1.33 to 4.09;
P=0.003) by multivariate
analysis.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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This study demonstrates that in diabetic patients restenosis after coronary balloon angioplasty is a major determinant of long-term mortality. The deleterious effect of restenosis on survival is related mainly to a high rate of coronary occlusion (14% of lesions, 18% of patients) and is independent of other risk factors previously described in this population.
Possible Mechanisms for the Diabetes-PTCA
Interaction
It is now well established that long-term survival of
diabetic patients with multivessel coronary artery disease treated by
standard coronary balloon angioplasty is significantly lower than after
bypass
surgery,2 7 8
a trend that is not seen in the nondiabetic
population.2 This unique
behavior suggests a specific interaction between diabetes mellitus and
the "response" of coronary vessels to balloon angioplasty. Although
several possible mechanisms have been suggested for this diabetes-PTCA
interaction,9 10 11 12
no conclusive explanation has been provided.
Early procedural complications, progression of atherosclerosis, or high restenosis rates are generally cited as potential explanations for the poor outcome of diabetic patients treated by standard balloon angioplasty. However, one of the most intriguing findings in several different studies was the fact that diabetics had a relatively low rate of in-hospital complications and that the detrimental effects of angioplasty became apparent only at a distance from the procedure.2 6 8 Considering this observation, as well as biological and epidemiological perspectives, the possibility that atherosclerosis progression may contribute to adverse outcome in this population is a plausible hypothesis.11 12 However, data on this subject are sparse.15 Although the present study was not specifically designed to investigate this issue, it is interesting to note that the rate of spontaneous occlusion(s) at untreated sites was relatively high in our population, 3% during a 6-month period, and that this parameter was an independent predictor of cardiac mortality.
Finally, although diabetes mellitus is a well-established risk factor for restenosis after balloon angioplasty,4 16 restenosis is generally not considered as the explanation for the high mortality rate observed in this population.10 12 15 Indeed, studies investigating the effect of restenosis on long-term follow-up in unselected populations did not demonstrate a significant impact of restenosis on survival.17 The assumption that restenosis could not be the explanation for the poor outcome of diabetic patients treated by PTCA was recently called into question by some new findings.4 13
Coronary Occlusion and Long-Term
Mortality
We recently reported that restenosis in diabetic
patients treated by balloon angioplasty had a unique feature, namely
the frequent occurrence of coronary occlusion (TIMI flow=0 or 1) at
dilated sites, that was observed in 14% of
lesions4 13
compared with 3% in nondiabetic
patients.13 From this
observation, we hypothesized that restenosis might be one of the
determinants of the poor outcome of diabetic patients after PTCA. The
present study involving a population of 604 consecutive diabetic
patients successfully treated by balloon angioplasty at 1 sites, with
6-month angiographic follow-up in 87% of patients and long-term
clinical follow-up (6.5 years) in 99.8% of patients, was specifically
designed to investigate this issue. The results of the study confirmed
our previous observation in that coronary occlusion was observed in
15% of treated lesions. This led to a higher risk of occlusion in
patients with multisite angioplasty and to an overall rate of coronary
occlusion of 18% in our population. More importantly, our study
demonstrated that restenosis, especially in its occlusive form, was a
strong predictor of poor long-term survival in diabetic
patients.
Multivariate analysis demonstrated that the effect of coronary occlusion was independent of other risk factors previously described in this population (age, end-organ damage, hypertension, baseline LVEF, and multivessel disease).3 6 8 It demonstrated also that the deleterious effect of coronary occlusion on survival was not exclusively related to the decrease in LVEF observed at the time of angiographic follow-up. This finding is consistent with previous observations18 19 and suggests that additional mechanisms, including late ventricular remodeling, improvement in electrical stability, and provision of collaterals, may play a role.20
It is also interesting to point out that the number of
treated lesions per patients, in addition to being a predictor of
coronary occlusion
(Table 1), was a predictor of mortality by univariate
analysis
(Table 3). However, because this parameter was also strongly
correlated with the severity of coronary artery disease and the risk of
occlusion, we were unable to demonstrate its effect on late outcome by
multivariate analysis.
It is important to emphasize that our results suggest that the status (patent/occluded) of dilated segments at 6 months may allow a better assessment of long-term prognosis than clinical symptoms in diabetic patients. Indeed, coronary occlusion was associated with clinical instability in <40% of cases, and clinical symptoms at the time of restudy were not a correlate of survival by multivariate analysis.
Clinical Implications
The present demonstration of the deleterious effect of
restenosis on long-term survival is potentially of major clinical
importance. Diabetics represent a large proportion of patients referred
for coronary
revascularization,2 3 4 5
and it will be very difficult from a practical viewpoint to refer all
diabetics for bypass surgery. Better insight into the causes of their
poor outcome might help to specifically design and test new therapeutic
approaches that could make PCR a safer technique in these patients.
Although the results of this study do not prove that occlusion of
target sites is the only reason for the poor outcome of diabetic
patients, they strongly suggest that it is a key part of the problem.
Our findings also raise the possibility that strategies designed to
minimize late coronary occlusion after angioplasty may improve the
outcome of these patients. Several recent observations lend support to
this
hypothesis.5 13 21 22
It is encouraging to see that the use of stents in diabetic patients
has been associated with a more acceptable risk of late occlusion
(
5% per lesion) than after standard balloon
angioplasty.13 21
Similarly, subgroup analyses of studies that investigated the effects
of the potent antiplatelet agent abciximab suggest that the beneficial
effect of this drug in reducing major adverse cardiac events after PCR
is even more potent in diabetics than in the population at
large.5 22 Our
previous demonstration that some angiographic characteristics,
including angioplasty at saphenous vein graft, thrombus, or TIMI flow
<3 before angioplasty and the degree of residual stenosis after
angioplasty, were found to predict restenosis and late vessel occlusion
in diabetic patients is also consistent with a potential benefit of
these 2 strategies.4 In the
light of our observation, we may even suggest that the apparent
reduction in major cardiac events at 1 year observed with the combined
use of stent and abciximab in diabetic patients, as reported in the
EPISTENT trial,22 was
probably related to an improved midterm patency of treated
vessels.
Study Limitations
Because this is a single-center retrospective study and
because patient referral, the technique of PTCA, or medical management
may have influenced the outcome, our results warrant confirmation by
other studies. However, because the rates of angiographic and long-term
clinical follow-up were very high in our population, our results are
likely to reflect the true rate of coronary occlusion and long-term
mortality in our study population. In addition, the technique of PTCA
is identical to the technique used in previous studies in which the
poor outcome of diabetic patients has been
demonstrated.2 3 6 7 8
Similarly, the characteristics of our study population, including
baseline patient characteristics, revascularization strategy (number of
lesions treated per patient), and mortality rate, are in the range of
what has been previously
reported.2 3 6 7 8
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Conclusions
Our results demonstrate that restenosis, especially in its occlusive form, is a key determinant of long-term survival in diabetic patients after standard balloon angioplasty. Strategies designed to target the problem of coronary occlusion might significantly affect long-term prognosis in diabetic patients treated by PCR.
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Acknowledgments |
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This work was supported in part by a grant from the Fondation de France.
Received July 14, 2000; revision received November 14, 2000; accepted November 16, 2000.
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References |
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