Ndei Cardiovascular Disease In Diabetes Prothrombotic Milieu

Diabetes: A Prothrombotic Milieu

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GUSTO-I: Reocclusion After Successful Thrombolysis Patency rate (%) Data from Woodfield SL et al. J Am Coll Cardiol . 1996;28:1661-1669. GUSTO-I=Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries; TIMI 3=Thrombolysis in Myocardial Infarction flow grade 3. Reocclusion rate (%) P =0.7 P =0.17

Composition of Coronary Atherectomy Specimens Diabetes No Diabetes Lipid-rich atheroma 7 ± 2% 2 ± 1% 0.01 Macrophages 22 ± 3% 12 ± 1% 0.003 Thrombus 62% 40% 0.04 Moreno PR et al. Circulation . 2000;102:2180-2184. Diabetes Atherectomy tissue immunostained with anti-human pan-macrophage antibody P No Diabetes

GP IIb/IIIa Inhibitors at Time of Angioplasty: EPIC, EPILOG, EPISTENT 1-Year mortality (%) Placebo Abciximab *P =0.01; † P =0.099; ‡ P =0.031. Data from Bhatt DL et al. J Am Coll Cardiol . 2000;35:922-928. 2.6 3.1 4.5 1.9 2.0 2.5 0 1 2 3 4 5 All (N=6,534) No diabetes (N=5,072) Diabetes (N=1,462) 26% RR 44% RR * † ‡

Effects of Coronary Stenting on Restenosis and Occlusion in Diabetes Data from Van Belle E et al. J Am Coll Cardiol . 2002;40:410-417. Balloon Stent 13 62 4 27 0 10 20 30 40 50 60 70 Restenosis Occlusion Patients with stenosis >50% at 6-mo follow-up (%) * † * P <0.0001; † P <0.005.

Effects of Coronary Stenting on Cardiac Death and MI in Diabetes Van Belle et al. J Am Coll Cardiol . 2002;40:410-417. Stent Balloon Years P =0.02 10 0 Incidence of cardiac death/nonfatal MI (%) 5 15 20 25 30 0 1 2 3 4 40% RR

SIRIUS: Effects of Sirolimus-Coated Stents on Restenosis Rates Data from Moussa I et al. Circulation . 2004;109:2273-2278. * P <0.001. Uncoated Sirolimus-coated Patients with in-lesion restenosis (%) 0 10 20 30 40 50 60 50.5 17.6 Diabetes 65% RR 30.7 6.0 No diabetes 80% RR * *

Incidence of Cardiac Events in Patients Undergoing PCI Time (days) Probability of freedom from event PCI=percutaneous coronary intervention. Kabbani SS et al. Circulation . 2001;104:181-186. 0 30 60 90 0.6 0.7 0.8 0.9 1.0 P =0.01 Low Platelet Reactivity Group High Platelet Reactivity Group

The Influence of Glucose on Platelet Function Keating FK et al. Am J Cardiol . 2003;92:1362-1365. Percentage of platelets binding fibrinogen Capacity to Bind Fibrinogen * P <0.05 for trend by repeated measures ANOVA. ADP=adenosine diphosphate. Concentration of ADP (  mol/L) Control (no added glucose) 27.5 mmol/L glucose 55 mmol/L glucose 60 40 20 0 * * * 0 0.2 1

The Influence of Glucose on Platelet Function (cont.) Keating FK et al. Am J Cardiol . 2003;92:1362-1365. Percentage of platelets expressing P-selectin P-Selectin Expression * P <0.05 for trend and for all glucose concentrations compared with control. Concentration of ADP (  mol/L) Control (no added glucose) 27.5 mmol/L glucose 55 mmol/L glucose 0 0.2 1 60 40 20 0 * * *

Mortality in Patients With Diabetes and Non–ST-Segment Elevation ACS

Meta-analysis :

PURSUIT

PRISM

PRISM-PLUS

GUSTO IV

PARAGON A

PARAGON B

30-Day mortality (%) Data from Roffi M et al. Circulation . 2001;104:2767-2771. P =0.007 P =0.99 ACS=acute coronary syndrome.

PCI-CURE: Pretreatment With Aspirin and Clopidogrel Subgroup Analysis* Adapted from Mehta SR et al. Lancet. 2001;358:527-533. Diabetes 16.5% 12.9% 0.77 (0.48-1.22) No diabetes 11.7% 7.9% 0.66 (0.50-0.87) RR (95% CI) Placebo † Clopidogrel † Placebo Better Clopidogrel Better Relative Risk 0.2 1.0 1.4 *CV death or MI at 1 year. † In combination with standard therapy. PCI-CURE=percutaneous coronary intervention-Clopidogrel in Unstable angina to prevent Recurrent Events.