1、糖尿病患者冠脈血運重建Aaron Kugelmass, MD, FACCChief of CardiologyDirector, Heart and Vascular CenterBaystate Medical Center/Tufts School of MedicineSpringfield, MA, USA申 明無糖尿病流行狀況全球發病率20002.8%(171 Million)20304.4% (366 Million)升高36% ! 在美國， 糖尿病患者占血運重建25%以上Stone, et al, Am J Card, 2007延長壽命（生存）改善生活質量（癥狀）心絞痛心衰心律失

2、常減少再住院等降低治療成本（社會經濟）冠心病治療目的Duke 數據: 校正后的17年生存曲線MEDCABGPCI血運重建-Smith PK et al. Ann Thorac Surg 82; 2006冠脈狹窄的部位和程度對心血管死亡的影響對29,082 患者（介入治療和藥物治療）7年隨訪結果-Duke 數據 心血管死亡風險患者人數02334374248505971768194981000 50%1支 5074%2或3支 5074%1支 75%2支 75%; 0 95%1支 95% Prox. LAD或 5074% LM2支 75%; 最少1支 95%2支 75% 且 LAD 95% 或 LM

3、 2549% 或 3支 75% 且 50%)血栓素/ 前列環素合成 活性依賴配體表達GP 2b/3aP 選擇素纖維蛋白原年輕血小板，血小板聚集能力P2Y1 抵抗 P2Y1 非依賴通路上調 臨床表現:支架內血栓形成 ACS再發GP 2b/3a 抑制劑使用受益Thienopyridine 抵抗糖尿病患者伴發血液高凝狀態粥樣斑塊組織因子含量增加tPA降低PAI-1增加纖維蛋白原增加 當斑塊出現裂隙或斑塊破裂，更容易發生嚴重臨床事件血運重建對于糖尿病患者血運重建是否可行？血管成形術后9年死亡率Kip et al. Circulation 1996;94:1818-1825裸支架血運重建DM 再狹窄率顯

4、著增高術后支架內 MLD病變長度 (mm)MLD (mm)10152025糖尿病2.535%39%43%46%3.023%26.530%33%4.015%17%19%22%非糖尿病2.525%27%30%33%3.017%19%22%25%3.510%12%14%16%4.06%7%8%10%Ho, et al, 1999藥物洗脫支架血運重建DES 顯著降低糖尿病患者支架再狹窄率.然而，相對風險依然存在.Stone, et al, Am J Cardiol, 2007冠脈搭橋血運重建生存率糖尿病患者術后生存率和非糖尿病患者相似BARI 試驗 4年隨訪結果Schwartz, et al, Cir

5、culation, 2002糖尿病-死亡- CABG STS 數據 30天死亡率JACC 2002;40:418-423% pts p0.001 p2 支血管病變心血管內外科醫生一致認為適合血運重建任意選擇 PCI (阿司匹林, 氯吡格雷, 阿昔單抗， sirolimus洗脫支架 vs 任意選擇 CABG (1 LIMA 橋)600 (例)2-5死亡，心肌梗死，腦卒中FREEDOM 適合 PCI 或 CABG，糖尿病患者，2 支血管病變Sirolimus洗脫支架 vs CABG2,400 (例)5死亡，心肌梗死，心血管事件糖尿病患者血運重建所有冠心病患者應該強化的藥物治理冠脈血運重建（PCI

6、和 CABG）是冠心病綜合治理的重要組成部分基本認識：血運重建受益隨患者心血管危險程度增高而增加，對于復雜冠脈病變， CABG 似乎優于PCI無論采取何種血運重建方法，糖尿病患者效果相對較差糖尿病患者血運重建選擇的基本方法同非糖尿病患者Coronary Revascularization in Diabetic PatientsAaron Kugelmass, MD, FACCChief of CardiologyDirector, Heart and Vascular CenterBaystate Medical Center/Tufts School of MedicineSpringfi

7、eld, MA, USADisclosuresNoneDiabetes Mellitus:An EpidemicWorld Wide Incidence of DM20002.8%(171 Million)20304.4% (366 Million)A 36% Increase!Diabetics Receive 25% of Revascularization Procedures in the USStone, et al, Am J Card, 2007Prolong life (mortality benefit)Improve quality of life (symptom ben

8、efit)anginaCHFarrhythmiasavoid procedures/rehospitalization, etcReasonable costs (societal benefit)Treatment for CAD: Goals of TherapyDuke Database: Adjusted 17-year SurvivalMEDCABGPCIRevascularization-Smith PK et al. Ann Thorac Surg 82; 2006Influence of Severity and Location of Stenosis on Cardiac

9、Death Over a 7-Year Mean Follow-up in 29,082 Patients Catheterized for CAD at Duke Between 19862000 and Treated Without RevascularizationRelative Chance of Cardiac DeathNumber of Patients0233437424850597176819498100None 50%One 5074%Two or Three 5074%One 75%Two 75%; None 95%One 95% Prox. LAD or 5074%

10、 LMTwo 75%; At least one 95%Two 75% with 95% LAD or 2549% LM or three 75% and 50% reduction)Thromboxane/ Prostacyclin Synthesis Activation Dependent Ligand ExpressionGP 2b/3aP SelectinFibrinogenPlatelet Turnover-younger, more aggregable plateletsP2Y1 Resistance Up-regulation of P2Y1 independent path

11、waysClinical Manifestations include:Stent ThrombosisRecurrent ACSBenefit of GP 2b/3a InhibitorsThienopyridine ResistanceDiabetes Results in a Hypercoaguble State (Soluble Clotting Cascade)Atheroma Contains Increased Tissue FactorDecreased tPAIncreased PAI-1Increased FibrinogenWhen Plaques Fissure or

12、 Rupture, They Are More Likely to Result in a Major Clinical EventRevascularizationAre Revascularization Methods as Durable in Diabetics? Nine-Year Mortality After AngioplastyKip et al. Circulation 1996;94:1818-1825Revascularization DurabilityBare Metal StentsDM Have Significantly More RestenosisPos

13、t-ProcedureMLDLesion Length (mm)In-Stent MLD(mm)10152025Diabetic2.535%39%43%46%3.023%26.530%33%4.015%17%19%22%Nondiabetics2.525%27%30%33%3.017%19%22%25%3.510%12%14%16%4.06%7%8%10%Ho, et al, 1999Revascularization DurabilityDrug Eluting StentsDES significantly reduce restenosis in diabetics.However, a

14、 significant hazard still exists.Stone, et al, Am J Cardiol, 2007Revascularization DurabilityCABG and Graft SurvivalDiabetic Bypass Intermediate Graft Survival Appears to be Similar to that of Non-Diabetics4 Year Graft Survival in the BARI TrialSchwartz, et al, Circulation, 2002Diabetes, Mortality a

15、nd CABGSTS Database 30 Day MortalityJACC 2002;40:418-423% pts p0.001 p2 vessel CADConsensus by cardiologist and surgeon that patient is suitable for revascularizationOptional PCI (aspirin, clopidogrel, abciximab and sirolimus-eluting stents vs optional CABG (1 actual graft with LIMA to CAD)600 (proj

16、.)2-5 yearsDeath, MI, strokeFREEDOM Diabetes with 2 vessel CAD suitable for PCI or CABGPCI with sirolimus-eluting stents vs CABG2,400 (proj.)5 yearsDeath, MI, CVACoronary Revascularization Among DiabeticsAll CAD patients deserve intensive medical RxCoronary revascularization with PCI and CABG are important components of an integrated treatment paradigm for all patients CAD.Fundamental tenet in revascularization is that overa