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Coronary stent selection in the diabetic patient.

Which is the best coronary stent in diabetic patients with stable angina? This is a question that has vexed cardiologists, and this recent publications suggests that the question is still a valid. They did show that in diabetes it is preferable to have more that 6 months of aspirin plus clopidogrel after stent implantation. We use 1 year as standard. In addition, there did not seem to be any increase in mortality with the use of drug eluting stents, a worry raised by other smaller publications. The reason to use drug eluting stents is to lower the risk of renarrowing. Angioplasty, when done for angina, is never really done to make you live longer. It helps angina, and the medication, such as statins, blood pressure tablets, and the aspirin, make you live longer. all the drug eluting stents appear to be better than bare metal stents in terms of keeping renarrowing at bay. There was no change in death rate between stents or the risk of stent thrombosis. The everolimus eluting stent might have a slight advantage over the sirolimus and plaxitaxol eluting stents, but all are better than bare metal stents.

The other debate is of course whether diabetes plus coronary disease means that coronary bypass surgery Is better that stents. That question should be answered on an individual basis, after a full assessment of the risks of both procedures. The trials suggests that at least short term, survival rates are the same for both treatments, but the price to pay for the smaller angioplasty procedure is that you may need repeat procedures due to renarrowing, despite drug eluting stents, whereas the price for bypass surgery is much larger procedure and a small increased risk of stroke. I was involved in the first trial comparing bypass surgery to stents purely in diabetic patients. Even out to 5 years of followup, there is on difference in mortality that can gets be seen between the treatments.

For your reference:
Sirolimus eluting stent= Cypher
Plaxitaxel eluting stent= Taxus
Zotarolimus eluting stent= Endeavour
Everolimus eluting stents= Xience
http://www.bmj.com/content/345/bmj.e5170
http://www.bmj.com/content/341/bmj.c6975

 

Posted on 10 October 2012
Author: LCC
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