糖尿病冠心病之血管重建(英文)

Revascularization of coronary artery disease in diabetic patients

发病率和死亡率相关CAD仍然是对糖尿病患者的巨大挑战。糖尿病的血小板功能异常,两个糖蛋白Ⅰb和Ⅱb/Ⅲa受体的表达增加,使扩张血小板血管性假血友病因子和血小板纤维蛋白相互作用,而导致糖尿病患者死亡和血栓性并发症的风险增加。多项研究表明:成功进行PCI后血管再建更需反复,临床疗效差,DM仍然是一个极高的危险因素。虽然资料表明,药物洗脱支架(DES)可减少阻塞率及重复再建血管与糖尿病状况无关,但治疗的终点结果如心肌梗塞,死亡率没有实质上的减少。然而,也有许多其他随机试验比较多支的PCI使用DES或金属裸支架(BMS)跟冠状动脉搭桥术(CABG),冠状动脉搭桥术优越性对糖尿病患者一直具有优越性。糖尿病患者和多支冠状动脉病变,选择最优策略心肌血运重建是至关重要的。血运重建策略必须考虑到狭窄和移植物闭塞的风险较高,以及病后遗症使糖尿病的介入治疗复杂化。当选择PCI时,应倾向于使用DES和强有力的血小板抑制剂。当选择冠状动脉搭桥术时,要考虑在围术期脑卒中的减少,伤口感染的减少,手术后的医疗管理的优化选择时,要有利于糖尿病患者。患者的血糖控制有利于这两个策略。

Morbidity and mortality related to CAD remain a great challenge in patients with DM.Platelet function is abnormal in diabetes,expression of both glycoprotein Ib and Ⅱb/ Ⅲa is increased,augmenting both platelet-von Willebrand factor and platelet-fibrin interaction which leads to an increased risk of death and thrombotic complications in diabetics compared with nondiabetic patients.Multiple studies have shown that DM is a strong risk factor for restenosis following successful percutaneous coronary intervention (PCI) with greater need for repeat revascularization and inferior clinical outcomes though early data available suggest that drug eluting stents (DES) reduce restenosis rates and the need for repeat revascularization irrespective of the diabetic state and with no significant reduction in hard clinical endpoints such as myocardial infarction and mortality.However,there are so many other randomized trials comparing multivessel PCI using DES or bare metal stent (BMS) to coronary artery bypass grafting (CABG) which consistently demonstrated the superiority of CABG in patients with DM.Selection of the optimal myocardial revascularization strategy for patients with DM and multivessel coronary artery disease is crucial.Strategies for revascularization must take into account the higher risk for restenosis and graft occlusion,as well as the comorbid sequelae that complicate interventions in diabetic patients.When opting for PCI,the use of DES and potent platelet inhibitors should be favoured.And when opting for CABG,reduction in perioperative stroke,wound infection,and optimization of post-operative medical management will be of benefit to diabetic patients.Glycaemic control is beneficial to both strategies.