Impact of drug-eluting stents among insulin-treated diabetic patients: a report from the National Heart, Lung, and Blood Institute Dynamic Registry

Abstract

Objectives: This study sought to evaluate the safety and efficacy of drug-eluting stents (DES) compared with bare-metal stents (BMS) in patients with insulin- and noninsulin-treated diabetes.

Background: Diabetes is a powerful predictor of adverse events after percutaneous coronary interventions (PCI), and insulin-treated diabetic patients have worse outcomes. The DES are efficacious among patients with diabetes; however, their safety and efficacy, compared with BMS, among insulin-treated versus noninsulin-treated diabetic patients is not well established.

Methods: Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated 1-year outcomes of insulin-treated (n = 817) and noninsulin-treated (n = 1,749) patients with diabetes who underwent PCI with DES versus BMS.

Results: The use of DES, compared with BMS, was associated with a lower risk for repeat revascularization for both noninsulin-treated patients (adjusted hazard ratio [HR] = 0.59, 95% confidence interval [CI] 0.45 to 0.76) and insulin-treated subjects (adjusted HR = 0.63, 95% CI 0.44 to 0.90). With respect to safety in the overall diabetic population, DES use was associated with a reduction of death or myocardial infarction (adjusted HR = 0.75, 95% CI 0.58 to 0.96). However, this benefit was confined to the population of noninsulin-treated patients (adjusted HR = 0.57, 95% CI 0.41 to 0.81). Among insulin-treated patients, there was no difference in death or myocardial infarction risk between DES- and BMS-treated patients (adjusted HR = 0.95, 95% CI 0.65 to 1.39).

Conclusions: Drug-eluting stents are associated with lower risk for repeat revascularization compared with BMS in treating coronary artery disease among patients with either insulin- or noninsulin-treated diabetes. In addition, DES use is not associated with any significant increased safety risk compared with BMS. These findings suggest that DES should be the preferred strategy for diabetic patients.

Keywords: Diabetes; Drug-eluting stents; Insulin; Percutaneous coronary intervention.

Conflict of interest statement

Conflicts: None

Figures

Figure 1

Repeat revascularization event rates. Kaplan-Meier 1-year curves of the incidence of the composite endpoint of post-discharge repeat PCI or CABG by diabetes treatment regimen and use of DES versus BMS.

Figure 2

Death or myocardial infarction event rates. Kaplan-Meier 1-year curves of the incidence of the composite endpoint of death or MI by diabetes treatment regimen and use of DES versus BMS.

Figure 3

Relative benefit of DES over BMS for safety and efficacy. Adjusted hazard ratios (solid rectangles) and 95% confidence intervals (horizontal lines) for safety and efficacy outcomes at 1-year comparing DES versus BMS (referent category) treated patients, stratified by diabetes treatment regimen. Variables adjusted for included: Age, vessel disease, history of congestive heart failure, hypertension, prior coronary intervention, peripheral vascular disease, history of hypercholesterolemia, number of significant lesions, renal disease, presence of total occlusion, tortuous lesion, unstable angina, AMI, cardiogenic shock, emergency procedure, urgent procedure, attempted an ostial lesion, attempted a class C lesion, attempted lesion receiving collaterals, attempted thrombus, and discharge medication (i.e. presence of at least 2 of the following: Beta blockers, Calcium blocker, Long acting nitrates, ACE inhibitors, statins, Clopidogrel/ticlopidine).