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Revascularisation in diabetics with multivessel coronary artery disease

Diabetic patients are recognised as being at high risk of vascular complications in a variety of situations. Approximately 80% will die of a cardiovascular event. In recent years there has been increasing recognition of the diversity of mechanisms responsible for prevalence of adverse events, although there are still many aspects that are poorly understood. Coronary artery disease is the major cause of death among diabetics and tends to be more severe and diffuse in this group. The growth of the diabetic population combined with recent technological and pharmacological advances in both bypass surgery and angioplasty make choosing the optimum revascularisation strategy in this group one of the most challenging issues facing the cardiologist today.

The exponential relation between the risk of developing diabetes mellitus (DM) and increasing body mass index ensures that the incidence of type 2 DM will rapidly increase if the current trend in western countries of increasing weight each succeeding generation continues. This is particularly relevant to immigrant communities moving to cultures enjoying a higher standard of living; not only do they have a higher incidence of diabetes, but their growth in population tends to be proportionately greater than the growth in the indigenous population. This statistic suggests that DM will continue to consume an increasing proportion of medical resources, not least the provisions set aside for the treatment of coronary artery disease.

Not only do diabetics have a greater complexity and extent of vascular disease in general, but they also have the additional disadvantages of having multisystem dysfunction involving endothelium, platelets, and renal and neurological systems.

The primary defect in type 2 DM is not fully understood, but the pathophysiology driving the disease process can be divided into four areas: endothelial dysfunction, platelet and clotting abnormalities, lipid abnormalities, and the consequences of hyperglycaemia, including protein and …