RESUMEN
OBJECTIVE: To estimate prevalence of diabetes in outpatient care and to describe its epidemiological characteristics, comorbidities, and related vascular complications. METHODS: Observational cross-sectional study which included all adults affiliated from a private insurance health plan on March 2019, at Hospital Italiano de Buenos Aires, from Argentina. RESULTS: The global prevalence of diabetes resulted in 8.5% with 95% CI 8.3-8.6 (12,832 out of a total of 150,725 affiliates). The age stratum with the highest prevalence was the group between 65 and 80 years old with 15.7% (95% CI 15.3-16.1). People with diabetes had a mean age of 70 years (SD 14), 52% were women, and the most frequently associated cardiovascular risk factors were: dyslipidaemia (88%), arterial hypertension (74%) and obesity (55%). In relation to metabolic control, 60% had at least one glycosylated hemoglobin measured in the last year, 70% of which were less than 7%. Almost 80% have LDL measured at least once in the last 2 years, 55% of them had an LDL value equal to or less than 100 mg/dl. The macrovascular complications present in order of frequency were: acute myocardial infarction (11%), cerebrovascular accident (8%) and peripheral vascular disease (4%); while the microvascular complications were found to be diabetic neuropathy (4%) and retinopathy (2%). 7% had diabetic foot, with less than 1% amputations. CONCLUSION: Diabetes represents a prevalent problem, even in elderly patients. This population continues to present a high cardiovascular risk, with little compliance with therapeutic goals.
OBJETIVO: Estimar la prevalencia de diabetes en atención ambulatoria y describir sus características epidemiológicas, comorbilidades y complicaciones vasculares relacionadas. MÉTODO: Corte transversal que incluyó la totalidad de adultos afiliados a la prepaga del Hospital Italiano de Buenos Aires en marzo de 2019, Argentina. RESULTADOS: La prevalencia global de diabetes resultó del 8.5% con intervalo de confianza del 95% (IC95%): 8.3-8.6 (12,832 de un total de 150,725 afiliados). El estrato etario con mayor prevalencia fue el grupo entre 65 y 80 años, con un 15.7% (IC95%: 15.3-16.1). Las personas con diabetes presentaban una media de edad de 70 años (desviación estándar: 14), el 52% eran mujeres, y los factores de riesgo cardiovasculares más frecuentemente asociados fueron: dislipidemia (88%), hipertensión arterial (74%) y obesidad (55%). En relación con el control metabólico, el 60% tenía al menos una hemoglobina glucosilada medida en el último año, siendo el 70% de estas menores al 7%. Casi el 80% tiene medido el colesterol vinculado a lipoproteínas de baja densidad (c-LDL) al menos una vez en los últimos dos años, de ellos el 55% presentaba un valor de c-LDL igual o menor a 100 mg/dl. Las complicaciones macrovasculares presentes en orden de frecuencia fueron: infarto agudo de miocardio (11%), accidente cerebrovascular (8%) y enfermedad vascular periférica (4%); mientras que las complicaciones microvasculares resultaron ser neuropatía diabética (4%) y retinopatía (2%). El 7% tuvo pie diabético, con menos del 1% de amputaciones. CONCLUSIONES: La diabetes representa un problema prevalente, incluso en pacientes ancianos. Esta población sigue presentando un elevado riesgo cardiovascular, con escaso cumplimiento de objetivos terapéuticos.
Asunto(s)
Atención Ambulatoria , Diabetes Mellitus , Angiopatías Diabéticas , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Atención Ambulatoria/estadística & datos numéricos , Argentina/epidemiología , Comorbilidad , Estudios Transversales , Complicaciones de la Diabetes/epidemiología , Diabetes Mellitus/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Angiopatías Diabéticas/epidemiología , Angiopatías Diabéticas/terapia , Hemoglobina Glucada/análisis , Factores de Riesgo de Enfermedad Cardiaca , Hipertensión/epidemiología , Seguro de Salud/estadística & datos numéricos , Prevalencia , Factores de RiesgoRESUMEN
Older patients with diabetes have a high risk of vascular complications. They have an increase of approximately 3 times for developing stroke compared with subjects without diabetes. In addition, up to 75-80% of deaths in diabetic patients are associated with major cardiovascular events including stroke. The risk of stroke is high within 5 years of diagnosis for type 2 diabetes is 9% (mortality 21%), that is more than doubles the rate for the general population. From observational registries in a collaborative stroke study in Mexico, we analyzed clinical data, risk factors, and outcome of 1182 diabetic patients with cerebral ischemia, with focus in elderly subjects. There was a high frequency of hyperglycemia during the acute phase of stroke: the median value was 140 mg/dL and 40% had values higher than 180 mg/dL. Clinical outcome was usually unfavorable in elderly stroke patients with diabetes: case fatality rate was 30% at 30 days and survivors had moderate to severe disability, usually as consequence of the propensity to develop more systemic medical complications during hospital stay. Primary stroke prevention studies in patients with diabetes reveal that tight control of glucose is not associated with reduction in stroke risk. Therefore, proper control of other vascular risk factors is mandatory in patients with diabetes, in particular of arterial hypertension.
Asunto(s)
Trastornos Cerebrovasculares/epidemiología , Diabetes Mellitus/epidemiología , Angiopatías Diabéticas/epidemiología , Anciano , Anciano de 80 o más Años , Glucemia/análisis , Daño Encefálico Crónico/epidemiología , Daño Encefálico Crónico/etiología , Daño Encefálico Crónico/prevención & control , Isquemia Encefálica/epidemiología , Isquemia Encefálica/etiología , Isquemia Encefálica/terapia , Trastornos Cerebrovasculares/diagnóstico , Trastornos Cerebrovasculares/fisiopatología , Trastornos Cerebrovasculares/prevención & control , Trastornos Cerebrovasculares/terapia , Comorbilidad , Diabetes Mellitus/fisiopatología , Angiopatías Diabéticas/fisiopatología , Angiopatías Diabéticas/prevención & control , Angiopatías Diabéticas/terapia , Susceptibilidad a Enfermedades , Femenino , Humanos , Resistencia a la Insulina , Masculino , Síndrome Metabólico/epidemiología , México/epidemiología , Persona de Mediana Edad , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Prevención Secundaria , Resultado del TratamientoRESUMEN
Diabetes mellitus (DM) is an independent risk factor for coronary heart disease, stroke, peripheral arterial disease and heart failure, which are the main causes of death in these patients. Moreover, patients with DM and cardiovascular disease have a worse prognosis than nondiabetics, present lower short-term survival, higher risk of recurrence of the disease and a worse response to the treatments proposed. In the last decades, diagnostic and therapeutic progress had already shown benefits concerning cardiovascular risk reduction in these patients, but their absolute mortality risk is still twice that of non-diabetic patients. Because of this, the adoption of intensive treatment, with strict cardiovascular risk factor control, is a priority. The present study presents the main clinical characteristics and also the practical approach for screening, diagnosis and treatment of patients with diabetic macrovascular disease.
Asunto(s)
Angiopatías Diabéticas/diagnóstico , Angiopatías Diabéticas/terapia , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/etiología , Enfermedad de la Arteria Coronaria/terapia , Angiopatías Diabéticas/etiología , Humanos , Enfermedades Vasculares Periféricas/diagnóstico , Enfermedades Vasculares Periféricas/etiología , Enfermedades Vasculares Periféricas/terapia , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/terapiaRESUMEN
Antecedentes: Los pacientes diabéticos tratados con angioplastía coronaria (AC) poseen un mayor riesgo de reestenosis y por lo tanto de reintervención en comparación a los no diabéticos, lo que ha derivado en una mayor utilización de stents recubiertos con drogas en este grupo de pacientes. Objetivo: Analizar la incidencia de reintervención en pacientes diabéticos no seleccionados sometidos a una AC con stent no recubierto en el Hospital Regional de Concepción e identificar los predictores de la reintervención. Método: Entre Enero 2005 y Diciembre 2006, 571 pacientes fueron sometidos AC, de los cuales 108 (19 por ciento) eran diabéticos. En este grupo estudiamos sus características clínicas, factores de riesgo y los factores angiográficos tales como el vaso tratado, diámetro, longitud y número de stents. Mediante un seguimiento telefónico y de ficha clínica se determinó la existencia o no de una reintervención coronaria. Identificado elgrupo con reintervención coronaria, comparamos las variables clínicas y angiográficas y a través de un modelo de regresión logística se buscó identificar predictores de dicha intervención. Se utilizó t de student y test exacto de Fisher. Resultados: La edad promedio fue 61±10 años, 71(66 por ciento) hombres y 25 por ciento insulinorequirientes 47(44 por ciento) pacientes tenía dislipidemia, 93(86 por ciento) hipertensión y 26(25 por ciento) eran fumadores. La AC fue en contexto de un SCA s/SDST en 56(52 por ciento) pacientes, 38 (35 por ciento) por IAM en evolución y 12(11 por ciento) por angina estable. Se implantaron 138 stents (1,3 stent/pt) y fue exitosa en el 96 por ciento. En el seguimiento de 13,7 ±7 meses la mortalidad fue 4,6 por ciento y sólo 12(11 por ciento) pacientes fueron sometidos a una nueva revascularización, 75 por ciento de las cuales fue otra AC. De las reintervenciones, sólo 4(33 por ciento) pacientes tenía reestenosis, el resto fue por lesiones en otro vaso. La distribución de los factores de riesgo...
Diabetes mellitus is associated to a more severe and extensive coronary artery disease. Coronary angioplasty (PTCA) has been demonstrated to have similar immediate results compared with patients without diabetes; however, diabetic patients exhibit a higher rate of restenosis and target lesion revascularization. Aim: to study the real incidence of a new interventional procedures in diabetics patients who were treated with bare metal stents. Methods: From January 2005 to December 2006, 571 patients were submitted to PTCA at the Hospital Regional de Concepcion. 108 patients (195) were diabetics. Clinical characteristics, risk factors, and angiographic findings were tabulated. Telephone follow up was used to determine the performance of coronary re intervention. A logistics regression model was used to identify predictors of coronary re intervention. Results: The mean average age was 61±10 years, 66 percent were men and 25 percent required insulin treatment. Dyslypidemia was present in 86 percent, hypertension in 86 percent and 25 percent were smokers. Indication for PTCA was acute coronary syndrome in 52 percent, myocardial infarction in 35 percent and stable angina in 11 percent. They received 1,3 stents/pts and immediate success rate was 96 percent. During follow up (13,7±7 months) global mortality was 4,6% and only 12 (11 percent) patients had a second revascularization procedure, 67 percent of them performed in non stentedcoronary arteries. Four revascularizations (33 percent) were due to significant in-stent restenosis, seven (58 percent) to other significant lesions and 1 to subacute stent thrombosis. In the univariate and multivariate analysis we didnot find independent clinical or angiographic factors as predictors of new revascularization. However, it wasmore frequent in patients with proximal left anterior descending artery stents and long lesions (58 percent and 50 percent, respectively). Conclusion: In our experience, need for repeat...
Asunto(s)
Humanos , Masculino , Adulto , Femenino , Persona de Mediana Edad , Angiopatías Diabéticas/terapia , Angioplastia Coronaria con Balón/efectos adversos , /complicaciones , Enfermedad Coronaria/terapia , Reoperación , Stents/efectos adversos , Chile , Angiografía Coronaria , Estudios de Seguimiento , Incidencia , Modelos Logísticos , Pronóstico , Recurrencia , Factores de Riesgo , Reestenosis Coronaria/etiología , Reestenosis CoronariaRESUMEN
O diabetes melito (DM) é um fator de risco independente para doença arterial coronariana, acidente vascular cerebral, doença vascular periférica e insuficiência cardíaca, que são as principais causas de morte nesses pacientes. Além disso, pacientes com DM e doença cardiovascular têm pior prognóstico, por apresentarem menor sobrevida, maior risco de recorrência da doença e pior resposta aos tratamentos propostos. Os avanços diagnósticos e terapêuticos das últimas décadas já mostram uma redução do risco de eventos cardiovasculares nesses pacientes, mas o risco absoluto desses é ainda duas vezes maior em relação ao dos pacientes não diabéticos. Portanto, é prioritária a adoção de um manejo intensivo, com controle rígido dos fatores de risco cardiovasculares. Esta revisão trata das principais características clínicas e apresenta uma abordagem prática do rastreamento, diagnóstico e tratamento da doença macrovascular nos pacientes com DM.
Diabetes mellitus (DM) is an independent risk factor for coronary heart disease, stroke, peripheral arterial disease and heart failure, which are the main causes of death in these patients. Moreover, patients with DM and cardiovascular disease have a worse prognosis than nondiabetics, present lower short-term survival, higher risk of recurrence of the disease and a worse response to the treatments proposed. In the last decades, diagnostic and therapeutic progress had already shown benefits concerning cardiovascular risk reduction in these patients, but their absolute mortality risk is still twice that of non-diabetic patients. Because of this, the adoption of intensive treatment, with strict cardiovascular risk factor control, is a priority. The present study presents the main clinical characteristics and also the practical approach for screening, diagnosis and treatment of patients with diabetic macrovascular disease.
Asunto(s)
Humanos , Angiopatías Diabéticas/diagnóstico , Angiopatías Diabéticas/terapia , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/etiología , Enfermedad de la Arteria Coronaria/terapia , Angiopatías Diabéticas/etiología , Enfermedades Vasculares Periféricas/diagnóstico , Enfermedades Vasculares Periféricas/etiología , Enfermedades Vasculares Periféricas/terapia , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/terapiaRESUMEN
BACKGROUND: Drug-eluting stents have been developed to reduce the rates of restenosis after coronary angioplasty. Several studies have demonstrated that rapamycin eluting stents are reliable and effective. AIM: To report the experience in our Health Centre with rapamycin-eluting stents. PATIENTS AND METHODS: Forty two stents with rapamicine were implanted to 32 diabetic patients, between June 2002 and December 2004. After the procedure, subjects were clinically followed-up for an average period of 19.9+/-9.9 months, evaluating functional capacity, angina pectoris, dyspnea, need for hospital admission, acute coronary events and cardiac death. In those subjects clinically suspected to have restenosis, a coronary angiography was performed. RESULTS: Twenty-nine subjects (90.6%) remained asymptomatic, two subjects (6.3%) developed angina pectoris but restenosis was ruled out, and one subject (3.1%) died. CONCLUSIONS: The use of rapamycin-eluting stents in these patients was safe and successful with no evidence of clinic restenosis. These positive results are similar to those reported in the Diabetes Study.
Asunto(s)
Angioplastia , Estenosis Coronaria/terapia , Angiopatías Diabéticas/terapia , Stents Liberadores de Fármacos , Inmunosupresores/uso terapéutico , Sirolimus/uso terapéutico , Distribución de Chi-Cuadrado , Reestenosis Coronaria/prevención & control , Diabetes Mellitus Tipo 2/terapia , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Resultado del TratamientoRESUMEN
INTRODUCTION: Vascular response at edges of drug-eluting stents is still not well established, particularly in diabetic patients who are prone to aggressive atherosclerosis progression. Recently, Biolimus and Zotarolimus have demonstrated potent antiproliferative effects. OBJECTIVE: To compare the vascular responses at edges of sirolimus analogous-eluting stents in patients with and without diabetes, using intravascular ultrasound (IVUS). METHODS: 306 edges were analyzed in 153 patients treated with drug-eluting stents and divided in: diabetics (122 edges) and nondiabetics (166 edges). IVUS was performed postintervention and at 6-month follow-up and included 5 mm distal and proximal to the stented segment. Vessel, lumen, and plaque volumes were calculated. Volume variation (follow-up minus basal) was also calculated. Edge restenosis was defined as obstruction >50%. RESULTS: Baseline characteristics were similar between groups. In both groups the entire lesion length was covered (stent length/lesion length ratio was 1.5 for both groups). There were no differences in edge volumes and restenosis rate between the groups. Among diabetics, there was no significant volume variation. However, in nondiabetic patients there was significant increase in vessel volume in proximal (from 67.1 +/- 22 mm(3) to 72.2 +/- 25 mm(3): P = 0.02) and distal (from 54.4 +/- 22 mm(3) to 59.8 +/- 22 mm(3): P = 0.001) edges. CONCLUSION: Nondiabetic patients showed a significant positive vascular remodeling in proximal and distal edges of sirolimus analogous-eluting stent. This vascular mechanism was not observed in diabetic patients. Although different vascular responses were observed, restenosis rates were equivalent between the 2 groups at 6-month follow-up.
Asunto(s)
Fármacos Cardiovasculares/administración & dosificación , Reestenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/terapia , Angiopatías Diabéticas/terapia , Stents Liberadores de Fármacos , Sirolimus/análogos & derivados , Sirolimus/administración & dosificación , Ultrasonografía Intervencional , Anciano , Estudios de Casos y Controles , Angiografía Coronaria , Estenosis Coronaria/diagnóstico por imagen , Angiopatías Diabéticas/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Factores de Tiempo , Resultado del TratamientoRESUMEN
Diabetic microangiopathy is responsible for an important rate of morbidity and mortality related to the disease. Endothelial damage seems to be the triggering factor in the pathogenesis of microvascular complications. Diabetes mellitus and other metabolic diseases are associated to endothelial dysfunction, the most precocious known marker of atherosclerosis. Changes on microvascular reactivity are present in patients with diabetes mellitus, as well as in individuals with risk factors for this disease. Evaluation of endothelial and microvascular functions is possible using different invasive or preferentially non-invasive methods. Adequate control of diabetes mellitus might postpone or perhaps even prevent the microvascular disease. Microvascular dysfunction, when seen only by changes on microvascular reactivity, could be ameliorated with correction of risk factors or drug treatment.
Asunto(s)
Aterosclerosis/etiología , Diabetes Mellitus Tipo 1/fisiopatología , Diabetes Mellitus Tipo 2/fisiopatología , Angiopatías Diabéticas/fisiopatología , Endotelio Vascular/fisiopatología , Enfermedad Crónica , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/terapia , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/terapia , Angiopatías Diabéticas/etiología , Angiopatías Diabéticas/terapia , Humanos , Microcirculación , Factores de RiesgoRESUMEN
Diabetes mellitus is a powerful risk factor for coronary artery disease. Diabetics demonstrate accelerated coronary atherosclerosis and worst prognosis following cardiac events. Although myocardial revascularization procedures result in more effective relieve of symptoms in patients with known coronary artery disease, there is no substantial evidence that this strategy improves outcome, except for specific situations. In addition, the benefit of myocardial revascularization is attenuated by the presence of metabolic abnormalities related to insulin resistance and other significant co-morbidities in diabetic patients. New advances recently developed for the clinical treatment of diabetes, as well as surgical and percutaneous approaches of myocardial revascularization, such as drug-eluting stents, seem to be promising therapeutical strategies for diabetic patients. Most importantly, treatment of type 2 diabetics with chronic coronary artery disease should consider the multifactorial pathogenesis of the disease and combine aggressive control of glycemic levels, strict management of all conventional risk factors, and lifestyle modification. The metabolic effects of insulin sensitizers over cardiovascular disease and mortality are under discussion. Ongoing clinical multicenter trials will probably define the real impact of new therapeutic modalities over the prognosis of diabetic patients.
Asunto(s)
Enfermedad de la Arteria Coronaria/terapia , Diabetes Mellitus Tipo 2 , Angiopatías Diabéticas/terapia , Revascularización Miocárdica , Angioplastia Coronaria con Balón , Enfermedad Crónica , Ensayos Clínicos como Asunto , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/terapia , Medicina Basada en la Evidencia , Humanos , Estudios Multicéntricos como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de RiesgoRESUMEN
Patients with diabetes and coronary artery disease are frequently considered for myocardial revascularization procedures, aiming at cardiovascular events risk reduction and a better quality of life. In clinical practice, decisions concerning surgery or percutaneous coronary intervention are frequently difficult, because of cases' severity, disease extension and co-morbidities association. Beyond that, the bulk of literature information was generated by subgroup analysis of randomized clinical trials, which were designed for the general population, not for diabetics. The aim of this study was to review literature on coronary percutaneous intervention in diabetic patients, and also to show recent data from the experience in this procedure at the Catheterization Laboratory of the Cardiology Institute of RS.
Asunto(s)
Angioplastia Coronaria con Balón/normas , Enfermedad de la Arteria Coronaria/terapia , Angiopatías Diabéticas/terapia , Angioplastia Coronaria con Balón/estadística & datos numéricos , Ensayos Clínicos como Asunto , Enfermedad de la Arteria Coronaria/cirugía , Medicina Basada en la Evidencia , Humanos , StentsRESUMEN
Background: Drug-eluting stents have been developed to reduce the rates of restenosis after coronary angioplasty. Several studies have demonstrated that rapamycin eluting stents are reliable and effective. Aim: To report the experience in our Health Centre with rapamycin-eluting stents. Patients and methods: Forty two stents with rapamicine were implanted to 32 diabetic patients, between June 2002 and December 2004. After the procedure, subjects were clinically followed-up for an average period of 19.9+9.9 months, evaluating functional capacity, angina pectoris, dyspnea, need for hospital admission, acute coronary events and cardiac death. In those subjects clinically suspected to have restenosis, a coronary angiography was performed. Results: Twenty-nine subjects (90.6 percent) remained asymptomatic, two subjects (6.3 percent) developed angina pectoris but restenosis was ruled out, and one subject (3.1 percent) died. Conclusions: The use of rapamycin-eluting stents in these patients was safe and successful with no evidence of clinic restenosis. These positive results are similar to those reported in the Diabetes Study.
Asunto(s)
Femenino , Humanos , Masculino , Persona de Mediana Edad , Angioplastia , Estenosis Coronaria/terapia , Angiopatías Diabéticas/terapia , Stents Liberadores de Fármacos , Inmunosupresores/uso terapéutico , Sirolimus/uso terapéutico , Distribución de Chi-Cuadrado , Reestenosis Coronaria/prevención & control , /terapia , Estudios de Seguimiento , Reproducibilidad de los Resultados , Resultado del TratamientoRESUMEN
INTRODUCTION: To get good results in the treatment of chronic diseases, we need the participation of patients who take decisions, where education is the most relevant factor. We analyze the limits and impact of an educational strategy during six group sessions through a month. OBJECTIVE: To evaluate clinical control in patients with diabetes and hypertension after group sessions. MATERIAL AND METHODS: It was included a group of 172 patients with diabetes and hypertension who went to a help group in 2003; There were two groups, a Group A with 88 patients who finished the educational strategy and a group B with 88 patients who left after the second session. RESULTS: The group A diminish glucose average -82 mg/dL (p<0.0001) and also lowered the systolic arterial tension -11.7 mm Hg (p<0.0001) and the diastolic tension -6.9 mm Hg (p<0.0001); there were not significant changes in group B. We used a repeated measured model 4 months before, during and 4 months after educational strategy, and there was a difference between the groups (p=0.008) and also the persistent effect after the educative strategy. CONCLUSION: We consider that improvement in clinical control was associated with the strategy used, because education motivate patients to take decisions to face real problematic situations, and helps them to think over life circumstances, and to have health live styles to control both diabetes and hypertension.
Asunto(s)
Diabetes Mellitus/terapia , Angiopatías Diabéticas/terapia , Hipertensión/terapia , Educación del Paciente como Asunto , Psicoterapia de Grupo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
A microangiopatia diabética ainda é responsável por importante taxa de morbidade e mortalidade relacionada à doença. O dano endotelial parece ser o fator desencadeante na patogênese das complicações microvasculares. O diabetes mellitus e outras doenças metabólicas estão associados à disfunção endotelial, que é o marcador mais precoce conhecido da aterosclerose. Alterações da reatividade microvascular estão presentes tanto em portadores de diabetes mellitus quanto em indivíduos com fatores de risco para essa doença. A avaliação das funções endotelial e microvascular é possível através de diferentes métodos invasivos ou não. O controle adequado do diabetes mellitus é capaz de retardar ou talvez mesmo prevenir a doença microvascular. A disfunção microvascular, quando expressa somente por alterações da reatividade microvascular, pode ser melhorada com a correção de fatores de risco ou uso de drogas.
Diabetic microangiopathy is responsible for an important rate of morbidity and mortality related to the disease. Endothelial damage seems to be the triggering factor in the pathogenesis of microvascular complications. Diabetes mellitus and other metabolic diseases are associated to endothelial dysfunction, the most precocious known marker of atherosclerosis. Changes on microvascular reactivity are present in patients with diabetes mellitus, as well as in individuals with risk factors for this disease. Evaluation of endothelial and microvascular functions is possible using different invasive or preferentially non-invasive methods. Adequate control of diabetes mellitus might postpone or perhaps even prevent the microvascular disease. Microvascular dysfunction, when seen only by changes on microvascular reactivity, could be ameliorated with correction of risk factors or drug treatment.
Asunto(s)
Humanos , Aterosclerosis/etiología , Diabetes Mellitus Tipo 1/fisiopatología , /fisiopatología , Angiopatías Diabéticas/fisiopatología , Endotelio Vascular/fisiopatología , Enfermedad Crónica , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/terapia , /complicaciones , /terapia , Angiopatías Diabéticas/etiología , Angiopatías Diabéticas/terapia , Microcirculación , Factores de RiesgoRESUMEN
Diabetes mellitus é um dos principais fatores de risco para a doença arterial coronária. A doença progride de forma mais acelerada em pacientes diabéticos e está associada com pior prognóstico. Embora a revascularização miocárdica garanta alívio rápido dos sintomas em pacientes com doença arterial coronária documentada, não existe substancial evidência de benefício prognóstico, salvo em situações anatômicas específicas. Adicionalmente, o benefício das terapias de revascularização é atenuado pela presença de anormalidades metabólicas secundárias à resistência à insulina e significantes co-morbidades. Nos últimos anos, avanços na terapêutica clínica (estatinas, antiplaquetários potentes, novos anti-hipertensivos) e técnicas de revascularização cirúrgica e percutânea ocorreram, sendo que o emprego de stents farmacológicos parece ser uma promissora opção terapêutica nesses pacientes. A estratégia de tratamento do paciente diabético com coronariopatia crônica deve levar em consideração a patogênese multifatorial da doença e visar uma intervenção agressiva do controle dos níveis glicêmicos e de todos os fatores de risco modificáveis, aliada à mudança no estilo de vida. Os efeitos não-metabólicos dos sensibilizadores de insulina sobre a vasculopatia e mortalidade nesses pacientes também estão em discussão. Estudos clínicos em andamento deverão definir o impacto das novas modalidades terapêuticas sobre o prognóstico dos pacientes diabéticos.
Diabetes mellitus is a powerful risk factor for coronary artery disease. Diabetics demonstrate accelerated coronary atherosclerosis and worst prognosis following cardiac events. Although myocardial revascularization procedures result in more effective relieve of symptoms in patients with known coronary artery disease, there is no substantial evidence that this strategy improves outcome, except for specific situations. In addition, the benefit of myocardial revascularization is attenuated by the presence of metabolic abnormalities related to insulin resistance and other significant co-morbidities in diabetic patients. New advances recently developed for the clinical treatment of diabetes, as well as surgical and percutaneous approaches of myocardial revascularization, such as drug-eluting stents, seem to be promising therapeutical strategies for diabetic patients. Most importantly, treatment of type 2 diabetics with chronic coronary artery disease should consider the multifactorial pathogenesis of the disease and combine aggressive control of glycemic levels, strict management of all conventional risk factors, and lifestyle modification. The metabolic effects of insulin sensitizers over cardiovascular disease and mortality are under discussion. Ongoing clinical multicenter trials will probably define the real impact of new therapeutic modalities over the prognosis of diabetic patients.
Asunto(s)
Humanos , Enfermedad de la Arteria Coronaria/terapia , Angiopatías Diabéticas/terapia , Revascularización Miocárdica , Angioplastia Coronaria con Balón , Enfermedad Crónica , Ensayos Clínicos como Asunto , /complicaciones , /terapia , Medicina Basada en la Evidencia , Estudios Multicéntricos como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de RiesgoRESUMEN
Os pacientes com diabetes e cardiopatia isquêmica são freqüentemente considerados para a realização de revascularização miocárdica com o objetivo de diminuição do risco de eventos cardiovasculares ou melhora da qualidade de vida. Na prática clínica, as decisões quanto à realização de cirurgia ou intervenção coronariana percutânea são freqüentemente difíceis, devido à gravidade dos casos, extensão da doença e presença de co-morbidades. Além disso, a maioria dos dados disponíveis na literatura origina-se da análise de subgrupos de ensaios clínicos delineados para estudos da população em geral, não para diabéticos. O objetivo deste estudo foi revisar a literatura quanto à intervenção coronária percutânea em pacientes com diabetes, além de mostrar dados mais recentes dos resultados deste procedimento no Serviço de Hemodinâmica do Instituto de Cardiologia do RS.
Patients with diabetes and coronary artery disease are frequently considered for myocardial revascularization procedures, aiming at cardiovascular events risk reduction and a better quality of life. In clinical practice, decisions concerning surgery or percutaneous coronary intervention are frequently difficult, because of cases' severity, disease extension and co-morbidities association. Beyond that, the bulk of literature information was generated by subgroup analysis of randomized clinical trials, which were designed for the general population, not for diabetics. The aim of this study was to review literature on coronary percutaneous intervention in diabetic patients, and also to show recent data from the experience in this procedure at the Catheterization Laboratory of the Cardiology Institute of RS.
Asunto(s)
Humanos , Angioplastia Coronaria con Balón/normas , Enfermedad de la Arteria Coronaria/terapia , Angiopatías Diabéticas/terapia , Angioplastia Coronaria con Balón/estadística & datos numéricos , Ensayos Clínicos como Asunto , Enfermedad de la Arteria Coronaria/cirugía , Medicina Basada en la Evidencia , StentsRESUMEN
We evaluated the influence of diabetes mellitus (DM) on clinical outcomes in patients with coronary artery disease treated with stent implantation. Between 1996 and 2000, 934 stents were implanted in 893 patients in our institution; 23% of them had DM. Clinical and angiographic characteristics and clinical outcomes of the patients with and without DM were prospectively included in a computerized database. Diabetics were older (61.5 +/- 10 vs. 59.8 +/- 11 years; p = 0.04) and had a higher prevalence of hypertension (69% vs. 62%; p = 0.09). The procedural clinical success rate (successful coronary stenting with residual stenosis < 30%, TIMI 3 flow and no in-hospital adverse clinical event) was lower in the diabetic group (88% vs. 92%; p = 0.05). In the 1-year follow up, diabetic patients showed higher rates of new target vessel revascularization (12.3% vs. 8%; p = 0.06), death (5.4% vs. 2.5%; p = 0.03) and major adverse cardiovascular events (MACE, new angioplasty, surgery, acute myocardial infarction or death: 16.3% vs. 9.3%; p = 0.003). Diabetes was independently associated to 1-year MACE on multivariate analysis (OR: 2.00; IC: 1.25-3.24; = 0.004). We concluded that DM is associated with higher complication and restenosis rates and a higher risk of long-term major cardiovascular events in patients treated with coronary stent implantation.