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Cardio Diabetes Medicine 2017 391

Percutaneous Coronary Intervention in The Man-

agement of Multi-Vessel CAD in Diabetics - is
There Still A Role After Freedom Trial

Dr. Puvi Seshiah, MD, FACC, FSCAI, FRCP (G)
Director, structural Heart Program,

TriHealth Heart Institute, Cincinnati

Abstract
Diabetes is a systemic vascular disease character- and EASD guidelines prescribe HbA1C < 7% in most
ized by hyperglycemia, dyslipidemia and end- organ patients.
damage. Macrovascular disease presents clinically as BP control is consistently correlated with CV events.
myocardial infarction, stroke and peripheral vascular In the UKPDS, BP control was twice as effective as
disease. Diabetes is a unique cardiovascular risk fac- glucose control in diabetic endpoints but all cause
tor that should be treated differently from other risk mortality and MI did not differ. In the ABCD trial dia-
factors. Current guidelines recommend that patients stolic BP < 75 mmHg decreased CVD events. VADT
with diabetes be treated as having a CAD equivalent.
trial showed DBP < 70 mmHg increased mortality.
Atherosclerosis is accelerated in diabetes predis- ACCORD- BP trial did not show a difference in SBP <
posing patients with diabetes to a 2 to4 fold lifetime 120 and SBP <140 mmHg. JNC-7 recommended target
increase in CAD, with 75% of patients with diabetes for Diabetics is < 130/<80 mmHg.
dying of a cardiovascular cause. Diabetics have a * Current guidelines recommend high dose statins –
substantially higher incidence of multi-vessel disease atorvastatin 80mg or rosuvastatin 40mg in patients
and a greater plaque burden at presentation, with the with diabetes.
extent and severity of CAD
* Aspirin 75mg-162mg/day is uniformly recommend-
proportional to the duration of diabetes.
ed.
Management of CAD in patients with diabetes pres- * Clopidogreluse was studied in the CHARISMA(4) tri-
ents a unique challenge due to the extensive disease al ( ~80% Diabetics) and clopidogrel plus aspirin was
– multivessel and complex coronary lesions. Multiple not significantly more effective than aspirin alone in
trials have tried to address the problem of treatment reducing the rate of myocardial infarction, stroke, or
of multi-vessel CAD and the effect of diabetes. Man- death from cardiovascular causes.
agement of these patients is indeed complex and
may need a multi-disciplinary team approach. In this * In patients with prior MI however Ticagrelor plus
chapter we will highlight management strategies for aspirin decreased death, MI and stroke rates in the
diabetics with CAD. PEGASYS(5) trial ( ~ 30% Diabetics)
* ACE inhibitors and Beta blockers have shown to
Contemporary Optimal Medical therapy decrease CV mortality and morbidity.
(OMT) in patients with CAD * In patients with diabetes, newer therapies such
Glycemic control in diabetes over a long term may as sodium-glucose transporter-2 inhibitors and glu-
help reduce CV endpoints and mortality. Recent tri- cagon-like peptide-1 receptor agonists have been
als- ACCORD(1), ADVANCE(2) and VADT(3) failed to shown to reduce the risk of cardiovascular outcomes.
show any mortality benefit from aggressive glycemic However these have not been studied as a strategy
control (HbA1C < 6%) and indeed in the ACCORD trial of OMT in CAD in DM.
there was a 22% increase in total mortality with in-
tensive therapy driven by CV mortality. Current ADA * Achieving multiple risk factor (RF) goals through

Cardio Diabetes Medicine