PDF herunterladen
Aktuelle Kardiologie 2019; 8(04): 274-279
DOI: 10.1055/a-0892-0732
Kurzübersicht
Georg Thieme Verlag KG Stuttgart · New York

Myokardiale Revaskularisation bei Patienten mit Diabetes mellitus

Myocardial Revascularization in Patients with Diabetes Mellitus
Paul Michael Haller
Universitäres Herz- und Gefäßzentrum UKE Hamburg GmbH, Allgemeine und Interventionelle Kardiologie
,
Dirk Westermann
Universitäres Herz- und Gefäßzentrum UKE Hamburg GmbH, Allgemeine und Interventionelle Kardiologie
› Institutsangaben
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
15. August 2019 (online)

Auch verfügbar auf
    Lizenzen und Reprints

Zusammenfassung

Patienten mit Diabetes mellitus stellen eine wesentliche Subgruppe aller Patienten mit koronarer Herzkrankheit dar. Unter anderem aufgrund des diabetesbedingten, oftmals aggressiven Voranschreitens der koronaren Herzkrankheit präsentiert sich diese Patientengruppe gewöhnlich mit einer komplexen Koronarmorphologie, unter anderem mit Befall mehrerer Gefäße und gegebenenfalls auch einer Beteiligung des linken Hauptstamms. Die Prognose dieser Patienten ist verglichen mit Patienten ohne Diabetes mellitus außerdem deutlich schlechter. Entsprechend herausfordernd ist die richtige Wahl der koronaren Revaskularisation bei symptomatischen Patienten. Zumal die meisten Patienten mit Diabetes mellitus einen Befall mehrerer Herzkranzgefäße aufweisen, sollte die Entscheidung über das weitere Vorgehen auf einer interdisziplinären Diskussion im Heart-Team beruhen. Denn vor allem im Langzeitverlauf profitieren Patienten mit Diabetes mellitus von einer Versorgung mittels aortokoronaren Bypasses, was sich mit einer Reduktion der Gesamtsterblichkeit und einer geringeren Rate an Myokardinfarkten zeigt.

Abstract

Patients with diabetes mellitus represent a large subpopulation of patients with coronary artery disease. Commonly, diabetes mellitus leads to an aggressive progression of coronary artery disease, wherefore patients often present with complex diseased vessels, usually involving multiple coronaries and potentially also the left main. Besides, the prognosis of patients with compared to without diabetes mellitus is usually worse. Hence, the right choice of coronary revascularization in symptomatic patients is challenging. In such case, the decisions should be based on an interdisciplinary discussion in the “Heart-Team”. Because, especially in the long-term course patients will benefit from aortocoronary bypass surgery, which is associated with a reduction of all-cause mortality and the incidence of myocardial infarction.

Was ist wichtig?

  • Die optimale Koronarversorgung von Patienten mit DM ist oftmals herausfordernd und wird unter anderem durch ein breites kardiovaskuläres Risikoprofil sowie eine meist progressive KHK mit (diffusem) Befall mehrerer Koronarien verkompliziert.

  • Zahlreiche Studien zeigen einen Vorteil im Langzeitverlauf zugunsten einer ACBP für die Versorgung von Patienten mit DM und Mehrgefäßerkrankung.

  • Essenziell ist der interdisziplinäre Diskurs unter Betrachtung der Komorbiditäten, der Koronarmorphologie und der OP-Tauglichkeit, um eine für den Patienten optimale Empfehlung auszusprechen.

Schlüsselwörter

myokardiale Revaskularisation - koronare Herzerkrankung - perkutane Koronarintervention - aortokoronarer Bypass - Diabetes mellitus

Key words

myocardial revascularization - coronary artery disease - percutaneous coronary intervention - coronary artery bypass surgery - diabetes mellitus
 

  • Literatur

  • 1 Nichols M, Townsend N, Luengo-Fernandez R. et al. European Cardiovascular Disease Statistics 2012. Brussels: European Heart Network; Sophia Antipolis: European Society of Cardiology; 2012
    Google Scholar
  • 2 Go AS, Mozaffarian D, Roger VL. et al. Executive summary: heart disease and stroke statistics – 2014 update: a report from the American Heart Association. Circulation 2014; 129: 399-410
    CrossrefPubMedGoogle Scholar
  • 3 Kannel WB, McGee DL. Diabetes and cardiovascular disease. The Framingham study. JAMA 1979; 241: 2035-2038
    CrossrefPubMedGoogle Scholar
  • 4 Glucose tolerance and mortality: comparison of WHO and American Diabetic Association diagnostic criteria. Lancet 1999; 354: 617-621
    CrossrefPubMedGoogle Scholar
  • 5 Guariguata L, Whiting DR, Hambleton I. et al. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 2014; 103: 137-149
    CrossrefPubMedGoogle Scholar
  • 6 Sarwar N, Gao P, Seshasai SR. et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 2010; 375: 2215-2222
    CrossrefPubMedGoogle Scholar
  • 7 Neumann JT, Sorensen NA, Schwemer T. et al. Diagnosis of Myocardial Infarction Using a High-Sensitivity Troponin I 1-Hour Algorithm. JAMA Cardiol 2016; 1: 397-404
    CrossrefPubMedGoogle Scholar
  • 8 Giraldez RR, Clare RM, Lopes RD. et al. Prevalence and clinical outcomes of undiagnosed diabetes mellitus and prediabetes among patients with high-risk non-ST-segment elevation acute coronary syndrome. Am Heart J 2013; 165: 918-925.e2
    CrossrefPubMedGoogle Scholar
  • 9 Marso SP, Mercado N, Maehara A. et al. Plaque Composition and Clinical Outcomes in Acute Coronary Syndrome Patients With Metabolic Syndrome or Diabetes. JACC Cardiovasc Imaging 2012; 5: S42
    CrossrefPubMedGoogle Scholar
  • 10 Kappetein AP, Head SJ, Morice M-C. et al. Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial. Eur J Cardiothorac Surg 2013; 43: 1006-1013
    CrossrefPubMedGoogle Scholar
  • 11 Koskinas KC, Siontis GC, Piccolo R. et al. Impact of Diabetic Status on Outcomes After Revascularization With Drug-Eluting Stents in Relation to Coronary Artery Disease Complexity: Patient-Level Pooled Analysis of 6081 Patients. Circ Cardiovasc Interv 2016; 9: e003255
    PubMedGoogle Scholar
  • 12 Cavalcante R, Sotomi Y, Mancone M. et al. Impact of the SYNTAX scores I and II in patients with diabetes and multivessel coronary disease: a pooled analysis of patient level data from the SYNTAX, PRECOMBAT, and BEST trials. Eur Heart J 2017; 38: 1969-1977
    CrossrefPubMedGoogle Scholar
  • 13 Neumann FJ, Sousa-Uva M, Ahlsson A. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2018; 40: 87-165
    PubMedGoogle Scholar
  • 14 Ibanez B, James S, Agewall S. et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; 39: 119-177
    CrossrefPubMedGoogle Scholar
  • 15 Roffi M, Patrono C, Collet JP. et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37: 267-315
    CrossrefPubMedGoogle Scholar
  • 16 Sanchez CE, Dota A, Badhwar V. et al. Revascularization heart team recommendations as an adjunct to appropriate use criteria for coronary revascularization in patients with complex coronary artery disease. Catheter Cardiovasc Interv 2016; 88: E103-E112
    CrossrefPubMedGoogle Scholar
  • 17 Frye RL, August P, Brooks MM. et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med 2009; 360: 2503-2515
    CrossrefPubMedGoogle Scholar
  • 18 Farkouh ME, Domanski M, Sleeper LA. et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 2012; 367: 2375-2384
    CrossrefPubMedGoogle Scholar
  • 19 Park SJ, Ahn JM, Kim YH. et al. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med 2015; 372: 1204-1212
    CrossrefPubMedGoogle Scholar
  • 20 Head SJ, Milojevic M, Daemen J. et al. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet 2018; 391: 939-948
    CrossrefPubMedGoogle Scholar
  • 21 Herbison P, Wong CK. Has the difference in mortality between percutaneous coronary intervention and coronary artery bypass grafting in people with heart disease and diabetes changed over the years? A systematic review and meta-regression. BMJ Open 2015; 5: e010055
    CrossrefPubMedGoogle Scholar
  • 22 Bangalore S, Toklu B, Feit F. Outcomes with coronary artery bypass graft surgery versus percutaneous coronary intervention for patients with diabetes mellitus: can newer generation drug-eluting stents bridge the gap?. Circ Cardiovasc Interv 2014; 7: 518-525
    CrossrefPubMedGoogle Scholar
  • 23 Stone GW, Sabik JF, Serruys PW. et al. Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease. N Engl J Med 2016; 375: 2223-2235
    CrossrefPubMedGoogle Scholar
  • 24 Milojevic M, Serruys PW, Sabik 3rd JF. et al. Bypass Surgery or Stenting for Left Main Coronary Artery Disease in Patients With Diabetes. J Am Coll Cardiol 2019; 73: 1616-1628
    PubMedGoogle Scholar
  • 25 Ramanathan K, Abel JG, Park JE. et al. Surgical Versus Percutaneous Coronary Revascularization in Patients With Diabetes and Acute Coronary Syndromes. J Am Coll Cardiol 2017; 70: 2995-3006
    CrossrefPubMedGoogle Scholar
  • 26 Pandey A, McGuire DK, de Lemos JA. et al. Revascularization Trends in Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease Presenting With Non-ST Elevation Myocardial Infarction: Insights From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (NCDR ACTION Registry-GWTG). Circ Cardiovasc Qual Outcomes 2016; 9: 197-205
    CrossrefPubMedGoogle Scholar
  • 27 Dangas GD, Farkouh ME, Sleeper LA. et al. Long-term outcome of PCI versus CABG in insulin and non-insulin-treated diabetic patients: results from the FREEDOM trial. J Am Coll Cardiol 2014; 64: 1189-1197
    CrossrefPubMedGoogle Scholar
  • 28 Armstrong EJ, Rutledge JC, Rogers JH. Coronary artery revascularization in patients with diabetes mellitus. Circulation 2013; 128: 1675-1685
    CrossrefPubMedGoogle Scholar