What is the optimal drug-eluting stent for percutaneous coronary intervention in patients with insulin-treated vs. non-insulin treated diabetes?

Abstract

Background: Patients with diabetes mellitus (DM) have increased adverse events post percutaneous coronary intervention (PCI), somewhat attenuated by use of drug-eluting stents (DES). DES choice is controversial, with studies showing increased late mortality with sirolimus-eluting stents (SES) compared to paclitaxel-eluting (PES) or bare-metal stents (BMS) and higher major adverse cardiac and cerebrovascular event (MACCE) rates with second generation everolimus (EES) vs. PES. Methods: We enrolled 4,579 diabetic patients undergoing PCI from 2005-2014 in the Melbourne Interventional Group registry. Characteristics and 12-month outcomes were compared between insulin-treated (ITDM) and non-ITDM patients and by stent type. Results: Diabetics receiving DES were more likely to be insulin-requiring ( p < 0.05) or undergoing PCI for restenosis ( p < 0.001). ST-elevation myocardial infarction (STEMI) patients more often received BMS ( p < 0.003 for SES and PES); even after propensity matching in STEMI, a significant hazard for MACCE in ITDM vs. non-ITDM patients (OR 1.48, 1.19-1.84) remained. Stents were longer and vessel size smaller in DES vs. BMS ( p < 0.0001). However, 12-month MACCE were higher in BMS vs. SES or PES ( p = 0.004 and p = 0.046) and did not differ between DES types. Conclusion: In ITDM, all DES resulted in lower 12 month MACCE than BMS. Overall, outcomes depend more on the presence and intensity of DM treatment than stent type, particularly for EES vs. PES or second-generation vs. first generation DES.