這篇應該是為了醫病共享決策SDM寫的
將藥物-氣球擴張術-傳統支架-藥物支架-可吸收藥物支架,冠狀動脈繞道手術放在一起做比較.
對於冠狀動脈心臟病介入治療，我的選擇是什麼？國泰醫院
圖片很長. 只擷取上部
2026年10月19日 星期一
轉貼-PCI 冠狀動脈介入性治療-血管支架種類與比較
2026-10-19 查詢 DM with TVD 剛好看到這篇.
這篇應該是為了醫病共享決策SDM寫的
將藥物-氣球擴張術-傳統支架-藥物支架-可吸收藥物支架,冠狀動脈繞道手術放在一起做比較.
對於冠狀動脈心臟病介入治療，我的選擇是什麼？國泰醫院
這篇應該是為了醫病共享決策SDM寫的
將藥物-氣球擴張術-傳統支架-藥物支架-可吸收藥物支架,冠狀動脈繞道手術放在一起做比較.
對於冠狀動脈心臟病介入治療，我的選擇是什麼？國泰醫院
DM患者合併三條主要冠狀動脈阻塞 from uptodate
2026-10-19
Coronary artery revascularization in stable patients with diabetes mellitus
uptodate 的 recommendations 本來是放最下面的. 為了方便快速瀏覽. 我挪到第一段
對於患有糖尿病和多支血管病變(尤其是複雜病變)且需要進行血管重建的患者，我們建議行冠狀動脈旁路移植術（CABG）而非經皮冠狀動脈介入治療（PCI）（第 1B級建議）。
For patients with diabetes and multivessel disease (particularly if it is complex) who require revascularization, we recommend CABG rather than percutaneous coronary intervention (PCI) (Grade 1B).
對於接受冠狀動脈繞道手術的糖尿病患者，我們建議進行雙側而非單側內乳動脈（ITA）移植（第 2C級）。對於70至75歲以上的患者，不宜行雙側ITA移植，因為雙側ITA移植在老年患者的存活獲益可能較小。
對於接受冠狀動脈繞道手術（CABG）後出現無法忍受的心絞痛復發的糖尿病患者，我們建議對合適的病變進行經皮冠狀動脈介入治療（PCI）以再次血運重建（第 2C級）。
對於接受冠狀動脈繞道手術的糖尿病患者，我們建議在手術中和術後嚴格控制血糖，以改善心臟和非心臟預後（第2C級）。
For patients with diabetes who undergo CABG, we suggest tight glycemic control intra- and postoperatively to improve both cardiac and noncardiac outcomes (Grade 2C).
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結果 OUTCOMES
在接受血運重建術的患者中，糖尿病患者佔比超過30%，這與糖尿病在一般人群中的盛行率約為10%以及糖尿病患者心血管疾病風險比非糖尿病人群高出2至3倍的情況相符。兩組患者的手術成功率相似，但無論採用經皮冠狀動脈介入治療（PCI）或冠狀動脈繞道手術（CABG），糖尿病患者術後的長期預後均差於非糖尿病患者，這可能反映了糖尿病患者合併症的負擔
Patients with diabetes comprise over 30 percent of those who undergo revascularization, consistent with the approximately 10 percent prevalence of diabetes in the general population and their two- to threefold increased risk for cardiovascular disease compared with the nondiabetic population. Procedural success is similar in the two groups, but long-term outcomes after revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) are worse in diabetic compared with nondiabetic patients which may reflect the burden of comorbidities in patients with diabetes [2].
SYNTAX試驗比較了經皮冠狀動脈介入治療（PCI）與冠狀動脈旁路移植術（CABG）在複雜冠狀動脈疾病（左主幹和/或三支血管病變）患者中的療效，該試驗納入了452例糖尿病患者[ 28 ]。五年追蹤結果顯示，接受PCI治療的患者（n=231）中，糖尿病患者的再次血管重建率較高（29% vs. 19%）。糖尿病患者的死亡率也較高（20% vs. 12%）。
●The SYNTAX trial, which compared PCI with CABG in patients with complex CAD (left main and/or three vessel disease), included 452 patients with diabetes [28]. At five-year follow-up, the rate of repeat revascularization of patients undergoing PCI (n = 231) was higher in patients with diabetes (29 versus 19 percent). Mortality was also increased in the diabetic population (20 versus 12 percent).
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冠狀動脈繞道手術後 After coronary artery bypass graft surgery
在接受擇期冠狀動脈繞道手術的患者中，糖尿病患者和非糖尿病患者的手術短期成功率相似。然而，在追蹤期間，糖尿病患者的死亡率和術後非致命性不良事件發生率較高。
Among patients who undergo elective CABG, the procedural short-term success rates are similar in patients with and without diabetes. However, during follow-up, death and adverse nonfatal outcomes after CABG are higher in patients with diabetes.
此外，糖尿病患者發生胸骨傷口感染和腎衰竭的風險更高[ 29-31 ]。有研究表明，對於胸骨傷口感染發生率高達14%的糖尿病患者，雙側乳內動脈（乳動脈）移植可能存在禁忌症[ 31 ]。圍手術期嚴格控制血糖以及在取血管過程中對乳內動脈進行骨骼化處理與較低的胸骨傷口感染率相關
In addition, the risk of sternal wound infection and kidney failure is higher in patients with diabetes [29-31]. It has been suggested that bilateral internal thoracic (mammary) artery grafting may be contraindicated in diabetic patients in whom the incidence of sternal wound infection is as high as 14 percent [31]. Maintenance of strict glycemic control during the perioperative period and skeletonization of the internal mammary artery during harvesting are associated with lower rates of sternal wound infection [32,33]. (See 'Intraoperative and postoperative glycemic control' below and "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Sternal wound infection and mediastinitis' and 'Internal thoracic artery grafts' below.)
儘管糖尿病似乎不會影響冠狀動脈繞道手術（CABG）後的院內死亡率，但糖尿病患者CABG術後的短期和長期存活率顯著降低。在多項大型觀察性研究中，與非糖尿病患者相比，糖尿病患者30天死亡率（5% vs. 2.5%）以及5年和10年死亡率（分別為22% vs. 12%和50% vs. 29%）均較高[ 29,30,34-42 ]。與死亡率類似，CABG術後非致命性不良冠狀動脈事件在糖尿病患者中也可能更為常見。一項納入超過12,000例患者的研究顯示，糖尿病與10年內免於經皮冠狀動脈介入治療（PCI）的比例顯著降低相關（83% vs. 86%），但在5年或10年內發生心肌梗塞或再次CABG的比例方面無差異[ 40 ]。另一項報告評估了在同一中心接受冠狀動脈旁路移植術 (CABG) 並進行過一次或多次重複血管造影的患者，並對他們進行了 ≥25 年的隨訪 [ 41 ]。糖尿病與動脈粥狀硬化進展或症狀復發的相對風險為 1.39 相關。
Although diabetes does not appear to affect in-hospital mortality after CABG, short- and long-term survival after CABG are significantly reduced in diabetic patients. In different large observational studies, compared with nondiabetic patients, patients with diabetes had higher mortality rates at 30 days (5 versus 2.5 percent) and at 5 and 10 years (22 versus 12 percent and 50 versus 29 percent, respectively) [29,30,34-42]. As with mortality, nonfatal adverse coronary outcomes after CABG also may be somewhat more common in diabetic patients. In a report of over 12,000 patients, diabetes was associated with a significantly lower rate of freedom from PCI at 10 years (83 versus 86 percent) but no difference in either MI or additional CABG at 5 or 10 years [40]. Another report evaluated 1615 patients who underwent CABG at a single center and had one or more repeat angiograms, and they were followed for ≥25 years [41]. Diabetes was associated with a relative risk of 1.39 for progression of atherosclerosis or recurrent symptoms.
●在12個月的整體試驗組中，PCI組的主要不良心腦血管事件發生率高於CABG組（17.8% [PCI] vs. 12.4% [CABG]；p = 0.002）。糖尿病亞組的結果也一致。
●In the overall trial cohort at 12 months, major adverse cardiac or cerebrovascular events were higher in the PCI group (17.8 percent [PCI] versus 12.4 percent [CABG]; p = 0.002). The results were consistent in the subgroup with diabetes.
●三年後，在糖尿病患者群組中，PCI組的主要不良心腦血管事件發生率高於CABG組（37% [PCI] vs. 22.9% [CABG]；p = 0.002）。接受PCI治療的糖尿病患者再次血管重建的需求也顯著高於CABG組（28% [PCI] vs. 12.9% [CABG]；p<0.001）[ 44 ]。
●At three years, in the cohort with diabetes, major adverse cardiac and cerebrovascular event rates were higher with PCI (37 percent [PCI] versus 22.9 percent [CABG]; p = 0.002). The need for repeat revascularization was significantly higher in patients with diabetes treated with PCI (28 percent [PCI] versus 12.9 percent [CABG]; p<0.001) [44].
●10 年時，接受 PCI 治療的患者與接受 CABG 治療的患者相比，死亡率無顯著差異（PCI 組 27% [n = 244] vs. CABG 組 24% [n = 211]；p = 0.09）。在糖尿病患者群組中，452 例患者獲得了 10 年追蹤結果，其中共有 150 例死亡。接受 PCI 治療的患者與接受 CABG 治療的患者相比，10 年死亡風險無差異（HR 1.10；95% CI 0.80-1.52）[ 5 ]。
●At 10 years, there were no significant differences in death between patients treated with PCI compared with CABG (27 percent [n = 244 with PCI] versus 24 percent [n = 211 with CABG]; p = 0.09). In the cohort with diabetes, in whom 10-year outcomes were available in 452, a total of 150 had died. There were no differences in the risk of death at 10 years in patients treated with PCI compared with CABG (HR 1.10; 95% CI 0.80-1.52) [5].
應理解，本試驗中使用的 DES（紫杉醇洗脫劑）已被證明療效較差，不如當前一代的 DES。
These data should be interpreted with the understanding that the DES used in this trial (paclitaxel-eluting) has been shown to be less effective and inferior to the current generation of DES.
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支架類型 Stent type —
與接受經皮冠狀動脈介入治療（PCI）並植入支架的一般患者族群類似，接受目前一代藥物洗脫支架（DES）的患者，其再狹窄率和後續血運重建率低於接受裸金屬支架或早期DES的患者[ 45-58 ]。最新一代超細支架可能降低目標病變失敗和心肌梗塞（MI）的發生率[ 59 ]。然而，一項針對糖尿病患者使用超細支架的患者層級統合分析並未顯示其具有更高的益處
Similar to the general population of patients who undergo PCI with stent placement, patients who receive current generation drug-eluting stents (DES) have a lower rate of restenosis and subsequent revascularization than those who receive either bare metal stents or early generation DES [45-58]. The newest generation of ultra-thin-strut stents may reduce target lesion failure and MI [59]. However, a patient-level meta-analysis of ultra-thin stents in patients with diabetes did not demonstrate increased benefit [60].
糖尿病患者經皮冠狀動脈介入治療（PCI）後，血糖值較低時，再狹窄率可能較低。一項2004年發表的分析提示了這一觀點，該分析納入了239例擇期PCI患者（其中179例為糖尿病患者，67%的患者接受了支架植入術），並在術前測量了糖化血紅蛋白（HbA1c）水平[ 61 ]。術前HbA1c≤7%的糖尿病患者，其12個月時的標靶血管血管重建率與非糖尿病患者相當（15% vs 18%），而HbA1c>7%的糖尿病患者的標靶血管血管重建率則顯著升高（34%）。然而，由於研究為非隨機觀察性研究，樣本量較小，且可能存在混雜因素，因此其結果的普遍適用性受到限制。
●The rate of restenosis after PCI in diabetic patients may be lower in the setting of lower glycemia. This was suggested in an analysis from 2004 of 239 patients (179 with diabetes) who underwent elective PCI (67 percent with stenting) after measurement of glycated hemoglobin (HbA1c) [61]. Diabetic patients with a preprocedural HbA1c ≤7 percent had a rate of target vessel revascularization at 12 months that was comparable to that in nondiabetic patients (15 versus 18 percent), while diabetic patients with an HbA1c >7 percent had a significantly higher rate of target vessel revascularization (34 percent). Generalization is limited by the study design (non-randomized observational study), its small size, and potential for confounding.
兩項小型隨機試驗評估了該方法的潛在療效，試驗中，接受經皮冠狀動脈介入治療（PCI）並植入支架的2型糖尿病患者被隨機分配至噻唑烷二酮類藥物組（吡格列酮或羅格列酮）或安慰劑組[ 62,63 ]。兩項研究均顯示，噻唑烷二酮類藥物組的血管攝影再狹窄率顯著低於安慰劑組。由於支架技術自這些研究開展以來已有所發展，因此需要進一步研究來證實該方法的療效和安全性，尤其是在使用藥物洗脫支架（DES）的情況下。
The potential efficacy of this approach has been evaluated in two small randomized trials in which patients with type 2 diabetes who underwent PCI with stenting were randomly assigned to either a thiazolidinedione (pioglitazone or rosiglitazone) or placebo [62,63]. In both studies, the rate of angiographic restenosis was significantly lower in the thiazolidinedione group. Further studies are required to confirm the efficacy and safety of this approach, particularly with the use of DES since stent technology has evolved since the conduct of these studies.
血脂相關因素Lipid-related factors —
降血脂治療是PCI術後患者二級預防措施的基石，旨在降低未來冠狀動脈事件的風險。
Lipid-lowering therapy is the cornerstone of secondary prevention measures to reduce future coronary events in patients following PCI.
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Coronary artery revascularization in stable patients with diabetes mellitus
uptodate 的 recommendations 本來是放最下面的. 為了方便快速瀏覽. 我挪到第一段
CABG 冠狀動脈繞道手術
PCI 經皮冠狀動脈介入性治療, 俗稱心導管
Revascularization 血管再通術
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Revascularization 有很多不同的中文翻譯. 都是講同樣的東西, 參考連結放在每個中/英文翻譯 |
總結與建議 SUMMARY AND RECOMMENDATIONS
●適應症: 對於病情穩定的患者，無論是否患有糖尿病，血管重建的適應症都相似
Indications – The indications for revascularization in stable patients are similar for those with and without diabetes. ●對於患有糖尿病和穩定性心絞痛但無明確血管重建標準的患者，我們建議先採用強化藥物治療，而非立即進行血管重建（2B級）Our approach to revascularization – For patients with diabetes and stable angina who do not have a clear indication for revascularization, we suggest intensive medical therapy as the initial strategy rather than immediate revascularization (Grade 2B).
For patients with diabetes and multivessel disease (particularly if it is complex) who require revascularization, we recommend CABG rather than percutaneous coronary intervention (PCI) (Grade 1B).
For patients with diabetes undergoing CABG, we suggest placement of bilateral, rather than single, internal thoracic artery (ITA) grafts (Grade 2C). It is reasonable to not perform bilateral ITA grafting in individuals older than 70 to 75 years, as the survival benefit from bilateral ITA may be small in older individuals.
對於接受冠狀動脈繞道手術（CABG）後出現無法忍受的心絞痛復發的糖尿病患者，我們建議對合適的病變進行經皮冠狀動脈介入治療（PCI）以再次血運重建（第 2C級）。
For patients with diabetes who have recurrence of unacceptable angina after CABG, we suggest repeat revascularization with PCI for appropriate lesions (Grade 2C).
For patients with diabetes who undergo CABG, we suggest tight glycemic control intra- and postoperatively to improve both cardiac and noncardiac outcomes (Grade 2C).
血運重建的適應症 INDICATIONS FOR REVASCULARIZATION
我們認為，對於病情穩定的患者，無論是否患有糖尿病，血管重建的適應症都相似。決定進行血管重建而非繼續藥物治療，主要考慮以下三種情況：
●儘管接受了最大程度的藥物治療，但仍出現活動受限症狀的患者。
●對於希望透過血運重建術改善生活品質的活躍患者，例如無法耐受藥物治療或希望提高活動量的患者，血運重建術是比藥物治療更有效的選擇。
●對於血管解剖結構異常、經證實血管重建可提高存活率的患者，例如左主幹冠狀動脈嚴重病變（CAD；管腔狹窄超過50%）或伴隨左心室射血分數（LVEF）降低和大面積潛在缺血性心肌的多支血管CAD。
We believe that the indications for revascularization in stable patients are similar for those with and without diabetes. The decision to proceed with revascularization, as opposed to continuing medical therapy, is made in three groups:
●Patients with activity-limiting symptoms despite maximum medical therapy.
●Active patients who want revascularization for improved quality of life compared with medical therapy, such as those who are not tolerating medical therapy or want to increase their activity level.
●Patients with anatomy for which revascularization has a proven survival benefit, such as significant left main coronary artery disease (CAD; greater than 50 percent luminal narrowing) or multivessel CAD with a reduction of left ventricular ejection fraction (LVEF) and a large area of potentially ischemic myocardium.
血管重建建議方式 OUR APPROACH TO REVASCULARIZATION
對於大多數患有多支血管或複雜病變且符合血管重建標準的糖尿病患者，冠狀動脈旁路移植術（CABG）優於經皮冠狀動脈介入治療（PCI）。這項選擇是基於隨機臨床試驗的結果。
FREEDOM試驗發現CABG可改善患者預後。
這些發現與SYNTAX試驗和一項病患層級的統合分析[ 4,5 ]的結果一致。
對於SYNTAX評分較低、單一或雙支血管病變且病變局部、適合PCI的患者，我們認為PCI是合理的替代方案。
對於三支血管病變且SYNTAX評分較低的患者，考慮PCI也並非不合理，特別是對於那些有局部狹窄且手術風險較高的患者。
For most patients with diabetes who have multivessel or complex disease and indications for revascularization (see 'Indications for revascularization' above), coronary artery bypass graft surgery (CABG) is preferable to percutaneous coronary intervention (PCI). This preference is based on the results of randomized clinical trials. The FREEDOM trial found that outcomes were improved with CABG. These findings are consistent with the SYNergy Between PCI With TAXus and Cardiac Surgery (SYNTAX) trial and a patient-level meta-analysis [4,5]. For patients with low SYNTAX score, single-, or two-vessel disease who have lesions that are focal and amenable to PCI, we believe that PCI is a reasonable alternative. In patients with three-vessel disease and a low SYNTAX score, it is not unreasonable to consider PCI, particularly for those with focal stenoses and increased surgical risk.
無論選擇何種治療方案，所有糖尿病合併冠心病患者應接受積極的危險因子降低治療，包括優化糖尿病管理、控制血壓、服用阿斯匹靈、進行降血脂治療，以及在必要時進行生活方式乾預，例如運動、飲食調整和戒菸。
Regardless of the procedure chosen, all patients with diabetes and CAD should be treated with aggressive risk factor reduction, including optimal management of diabetes, blood pressure control, aspirin, lipid lowering therapy, and lifestyle changes including exercise, dietary modifications, and smoking cessation when indicated.
結果 OUTCOMES
在接受血運重建術的患者中，糖尿病患者佔比超過30%，這與糖尿病在一般人群中的盛行率約為10%以及糖尿病患者心血管疾病風險比非糖尿病人群高出2至3倍的情況相符。兩組患者的手術成功率相似，但無論採用經皮冠狀動脈介入治療（PCI）或冠狀動脈繞道手術（CABG），糖尿病患者術後的長期預後均差於非糖尿病患者，這可能反映了糖尿病患者合併症的負擔
Patients with diabetes comprise over 30 percent of those who undergo revascularization, consistent with the approximately 10 percent prevalence of diabetes in the general population and their two- to threefold increased risk for cardiovascular disease compared with the nondiabetic population. Procedural success is similar in the two groups, but long-term outcomes after revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) are worse in diabetic compared with nondiabetic patients which may reflect the burden of comorbidities in patients with diabetes [2].
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對於穩定性心絞痛，血管重建與藥物治療Revascularization versus medical therapy for stable angina — 在糖尿病患者族群中，血管重建與最佳藥物治療的死亡風險和未來發生心肌梗塞的風險相似[ 6-9 ]。血管攝影或臨床風險高的患者可能從血管重建中獲益
Revascularization versus medical therapy for stable angina — In the broad population of patients with diabetes, risk of death and future myocardial infarction are similar between revascularization and optimal medical therapy [6-9]. Patients at high angiographic or clinical risk may benefit from revascularization [10].
目前關於血管重建與最佳藥物治療比較的最佳證據來自冠狀動脈繞道手術血管重建研究第二型糖尿病（BARI 2D）試驗[ 6,7 ]。在BARI 2D試驗中，2368例2型糖尿病合併非急性缺血性心臟病（定義為：主要心外膜冠狀動脈狹窄≥50%且運動負荷試驗陽性，或狹窄≥70%且有典型心絞痛症狀）的患者被隨機分配至立即血運重建（經皮冠狀動脈介入治療[PCI]或冠狀動脈旁路移植術[CABG]）聯合藥物治療組純治療組。最適合的血管重建方式（PCI或CABG）由研究者在隨機分組前決定。五年時，主要終點指標（存活率或無重大心血管事件發生率，如死亡、心肌梗塞[MI]或中風）在及時血管重建組和單純強化藥物治療組之間無顯著差異（分別為88.3% vs 87.8%和77.2% vs 75.9%）。然而，亞組分析顯示，冠狀動脈繞道手術（CABG）組的無重大心血管事件發生率顯著高於單純強化藥物治療組（77.6% vs 69.5%），這主要歸因於非致命性心肌梗塞的減少。在經皮冠狀動脈介入治療（PCI）組中，及時血管重建組與單純強化藥物治療組相比，主要不良心血管事件發生率無差異（77.0% vs 78.9%）。
Revascularization versus medical therapy for stable angina — In the broad population of patients with diabetes, risk of death and future myocardial infarction are similar between revascularization and optimal medical therapy [6-9]. Patients at high angiographic or clinical risk may benefit from revascularization [10].
目前關於血管重建與最佳藥物治療比較的最佳證據來自冠狀動脈繞道手術血管重建研究第二型糖尿病（BARI 2D）試驗[ 6,7 ]。在BARI 2D試驗中，2368例2型糖尿病合併非急性缺血性心臟病（定義為：主要心外膜冠狀動脈狹窄≥50%且運動負荷試驗陽性，或狹窄≥70%且有典型心絞痛症狀）的患者被隨機分配至立即血運重建（經皮冠狀動脈介入治療[PCI]或冠狀動脈旁路移植術[CABG]）聯合藥物治療組純治療組。最適合的血管重建方式（PCI或CABG）由研究者在隨機分組前決定。五年時，主要終點指標（存活率或無重大心血管事件發生率，如死亡、心肌梗塞[MI]或中風）在及時血管重建組和單純強化藥物治療組之間無顯著差異（分別為88.3% vs 87.8%和77.2% vs 75.9%）。然而，亞組分析顯示，冠狀動脈繞道手術（CABG）組的無重大心血管事件發生率顯著高於單純強化藥物治療組（77.6% vs 69.5%），這主要歸因於非致命性心肌梗塞的減少。在經皮冠狀動脈介入治療（PCI）組中，及時血管重建組與單純強化藥物治療組相比，主要不良心血管事件發生率無差異（77.0% vs 78.9%）。
The best available evidence regarding a comparison of revascularization and optimal medical therapy comes from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI) 2D trial [6,7]. In BARI 2D, 2368 patients with type 2 diabetes mellitus and nonacute ischemic heart disease (defined as either a ≥50 percent stenosis of a major epicardial coronary artery associated with a positive stress test or ≥70 percent stenosis and classic angina) were randomly assigned to either prompt revascularization (PCI or CABG) plus medical therapy or medical therapy only. The most appropriate mode of revascularization (PCI or CABG) was determined by the investigator prior to randomization. At five years, the primary end points of the rates of survival or freedom from major cardiovascular events (eg, death, myocardial infarction [MI], or stroke) did not differ significantly between the prompt revascularization group and the intensive medical therapy alone group (88.3 versus 87.8 percent and 77.2 versus 75.9 percent, respectively). However, in subgroup analysis, the rate of freedom from major cardiovascular events was significantly higher with CABG (77.6 versus 69.5 percent), predominantly attributable to a reduction in nonfatal MI. In the PCI stratum, there were no differences in major adverse cardiovascular events with prompt revascularization, when compared with intensive medical therapy alone (77.0 versus 78.9 percent).
在 COURAGE 試驗中，與初始藥物治療相比，在廣泛的患者群體中，初始經皮冠狀動脈介入治療 (PCI) 血管重建策略並未降低死亡或心肌梗塞的風險。然而，接受初始血管重建治療的患者在一年後無心絞痛的可能性更高（66% 對 58%）。在糖尿病患者亞組（n=766）中，接受初始藥物治療的患者與接受血管重建治療的患者有相似的心血管結局（HR 0.99；95% CI 0.73-1.32
In the COURAGE trial, an initial revascularization strategy with PCI did not reduce the risk of death or MI when compared with an initial trial of medical therapy in a broad group of patients . However, patients treated with initial revascularization were more likely to be free from angina at one year (66 versus 58 percent). In the subgroup of patients with diabetes (n=766), patients treated with initial medical therapy had similar cardiovascular outcomes as patients treated with revascularization (HR 0.99; 95% CI 0.73-1.32) [8,9].
在 ISCHEMIA 試驗中，慢性冠心病患者被隨機分配至介入治療組（藥物治療合併血管造影，如可行則行血管重建）或保守治療組（僅藥物治療，藥物治療失敗後行血運重建）。研究中，43% 的參與者患有糖尿病。在 ISCHEMIA 的一項糖尿病亞研究中，糖尿病患者在中位數為 3.1 年的追蹤期間死亡或心肌梗塞的風險增加（HR 1.49；95% CI 1.31-1.70）[ 11 ]。然而，根據初始介入治療策略與藥物治療，死亡或心肌梗塞的發生率並無差異。同樣，在 REVIVED-SCIS2 試驗中，納入了無心絞痛但存在左心室功能障礙且心肌存活證據的患者，其中 41% 患有糖尿病 [ 12 ]。在該研究中，接受經皮冠狀動脈介入治療的患者與接受藥物治療的患者相比，死亡或因心臟衰竭住院的風險相似。
In the ISCHEMIA trial, patients with chronic coronary disease were randomly assigned to an invasive (medical therapy plus angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). In this study, 43 percent of participants had diabetes. In a diabetes substudy of ISCHEMIA, participants with diabetes had increased hazards for death or MI over a median 3.1 years of follow-up (HR 1.49; 95% CI 1.31-1.70) [11]. However, there was no difference in death or MI according to initial invasive strategy versus medical therapy. Similarly, in the REVIVED-SCIS2 trial of patients without angina who had left ventricular dysfunction with evidence of myocardial viability, 41 percent had diabetes [12]. In this study, patients who had revascularization with percutaneous coronary intervention compared with medical therapy had similar risks of death or hospitalization for heart failure.
在 COURAGE 試驗中，與初始藥物治療相比，在廣泛的患者群體中，初始經皮冠狀動脈介入治療 (PCI) 血管重建策略並未降低死亡或心肌梗塞的風險。然而，接受初始血管重建治療的患者在一年後無心絞痛的可能性更高（66% 對 58%）。在糖尿病患者亞組（n=766）中，接受初始藥物治療的患者與接受血管重建治療的患者有相似的心血管結局（HR 0.99；95% CI 0.73-1.32
In the COURAGE trial, an initial revascularization strategy with PCI did not reduce the risk of death or MI when compared with an initial trial of medical therapy in a broad group of patients . However, patients treated with initial revascularization were more likely to be free from angina at one year (66 versus 58 percent). In the subgroup of patients with diabetes (n=766), patients treated with initial medical therapy had similar cardiovascular outcomes as patients treated with revascularization (HR 0.99; 95% CI 0.73-1.32) [8,9].
在 ISCHEMIA 試驗中，慢性冠心病患者被隨機分配至介入治療組（藥物治療合併血管造影，如可行則行血管重建）或保守治療組（僅藥物治療，藥物治療失敗後行血運重建）。研究中，43% 的參與者患有糖尿病。在 ISCHEMIA 的一項糖尿病亞研究中，糖尿病患者在中位數為 3.1 年的追蹤期間死亡或心肌梗塞的風險增加（HR 1.49；95% CI 1.31-1.70）[ 11 ]。然而，根據初始介入治療策略與藥物治療，死亡或心肌梗塞的發生率並無差異。同樣，在 REVIVED-SCIS2 試驗中，納入了無心絞痛但存在左心室功能障礙且心肌存活證據的患者，其中 41% 患有糖尿病 [ 12 ]。在該研究中，接受經皮冠狀動脈介入治療的患者與接受藥物治療的患者相比，死亡或因心臟衰竭住院的風險相似。
In the ISCHEMIA trial, patients with chronic coronary disease were randomly assigned to an invasive (medical therapy plus angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). In this study, 43 percent of participants had diabetes. In a diabetes substudy of ISCHEMIA, participants with diabetes had increased hazards for death or MI over a median 3.1 years of follow-up (HR 1.49; 95% CI 1.31-1.70) [11]. However, there was no difference in death or MI according to initial invasive strategy versus medical therapy. Similarly, in the REVIVED-SCIS2 trial of patients without angina who had left ventricular dysfunction with evidence of myocardial viability, 41 percent had diabetes [12]. In this study, patients who had revascularization with percutaneous coronary intervention compared with medical therapy had similar risks of death or hospitalization for heart failure.
為了進一步了解哪些患者可能從冠狀動脈旁路移植術（CABG）中獲益，BARI 2D 研究人員根據基線血管造影（心肌危險指數、冠狀動脈病變總數、既往冠狀動脈血運重建史和左室射血分數）和臨床變量（弗雷明漢風險評分）構建了一個風險評分[ 10 ]。然後，研究人員使用血管攝影變數、臨床變數或兩者結合，將患者分為高風險組和低風險組。在血管攝影風險最高的三分之一族群中，CABG 組的死亡、心肌梗塞或中風複合終點事件發生率顯著低於強化藥物治療組（24.8% vs. 36.8%），且在血管攝影和臨床風險均高的患者中，這種差異更為顯著（27.1% vs. 47.3%；儘管這項分析受限於亞組樣本量較小以及所用血管造影風險評分缺乏驗證，但它表明，在糖尿病患者中，血管造影和臨床風險最高的患者從冠狀動脈旁路移植術（CABG）中獲益最大。在CABG組被認為高風險的381例患者中，五年死亡、心肌梗塞或中風的發生率在CABG組為24.8%，在藥物治療組為36.8%。相較之下，在高風險PCI組中，PCI組和藥物治療組之間沒有差異（分別為29.7%和29.9%）。
In an attempt to understand further which patients might benefit from CABG, the BARI 2D investigators developed a risk score from baseline angiographic (myocardial jeopardy index, total number of coronary lesions, prior coronary revascularization, and LVEF) and clinical variables (Framingham Risk Score) [10]. Patients were then stratified into high- and low-risk subgroups using either angiographic or clinical variables or both. The composite endpoint of death, MI, or stroke occurred significantly less often in the CABG stratum than in the intensive medical therapy group (24.8 versus 36.8 percent) among those in the highest angiographic risk tertile, and this effect was even more pronounced in patients with both high angiographic and high clinical risk (27.1 versus 47.3 percent; hazard ratio 2.10, p = 0.0051). Although this analysis is limited by small sample size in subgroups and lack of validation of the angiographic risk score used, it suggests that in patients with diabetes, those at highest angiographic and clinical risk benefit the most from revascularization with CABG. In the 381 patients from the CABG stratum that were considered high risk, the rates of death, MI, or stroke at five years were 24.8 percent in the CABG arm and 36.8 percent in the medical therapy arm. In contrast, there were no differences between PCI and medical therapy in the high-risk PCI stratum (29.7 versus 29.9 percent).
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經皮冠狀動脈介入治療後 After percutaneous coronary artery intervention —
Among diabetic patients who undergo elective PCI, the procedural success rates are similar to patients without diabetes [13-17]. However, patients with diabetes have increased rates of long-term restenosis and progression of coronary disease compared with patients without diabetes, as well as lower rates of event-free survival [13-15,17-27]. The following are examples of this point:
在j-Cypher註冊研究中接受西羅莫司洗脫支架經皮冠狀動脈介入治療（PCI）的10778例患者的分析中，966例患者患有胰島素治療的糖尿病，3404例患者患有未接受胰島素治療的糖尿病，6378例患者無糖尿病[ 24 ]。三年後，胰島素治療組和未接受胰島素治療組的標靶病變血管重建率均顯著高於無糖尿病組（分別為19%、14%和10%）。糖尿病患者的再狹窄預測因子包括血管管徑較小、支架植入段長度較長、體重指數較低，這與冠心病患者的整體情況相似。
●In an analysis of 10,778 patients in the j-Cypher registry who underwent PCI with sirolimus-eluting stents, there were 966 patients with insulin-treated diabetes, 3404 with diabetes not treated with insulin, and 6378 without diabetes [24]. At three years, the rate of target lesion revascularization was significantly higher in the insulin-treated and noninsulin-treated diabetes groups compared with those without diabetes (19, 14, and 10 percent, respectively). Predictors of restenosis in diabetic patients included smaller vessel caliber, greater length of the stented segment, and lower body mass index, similar to the broad population of patients with CAD.
●In an analysis of 10,778 patients in the j-Cypher registry who underwent PCI with sirolimus-eluting stents, there were 966 patients with insulin-treated diabetes, 3404 with diabetes not treated with insulin, and 6378 without diabetes [24]. At three years, the rate of target lesion revascularization was significantly higher in the insulin-treated and noninsulin-treated diabetes groups compared with those without diabetes (19, 14, and 10 percent, respectively). Predictors of restenosis in diabetic patients included smaller vessel caliber, greater length of the stented segment, and lower body mass index, similar to the broad population of patients with CAD.
SYNTAX試驗比較了經皮冠狀動脈介入治療（PCI）與冠狀動脈旁路移植術（CABG）在複雜冠狀動脈疾病（左主幹和/或三支血管病變）患者中的療效，該試驗納入了452例糖尿病患者[ 28 ]。五年追蹤結果顯示，接受PCI治療的患者（n=231）中，糖尿病患者的再次血管重建率較高（29% vs. 19%）。糖尿病患者的死亡率也較高（20% vs. 12%）。
●The SYNTAX trial, which compared PCI with CABG in patients with complex CAD (left main and/or three vessel disease), included 452 patients with diabetes [28]. At five-year follow-up, the rate of repeat revascularization of patients undergoing PCI (n = 231) was higher in patients with diabetes (29 versus 19 percent). Mortality was also increased in the diabetic population (20 versus 12 percent).
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冠狀動脈繞道手術後 After coronary artery bypass graft surgery
在接受擇期冠狀動脈繞道手術的患者中，糖尿病患者和非糖尿病患者的手術短期成功率相似。然而，在追蹤期間，糖尿病患者的死亡率和術後非致命性不良事件發生率較高。
Among patients who undergo elective CABG, the procedural short-term success rates are similar in patients with and without diabetes. However, during follow-up, death and adverse nonfatal outcomes after CABG are higher in patients with diabetes.
此外，糖尿病患者發生胸骨傷口感染和腎衰竭的風險更高[ 29-31 ]。有研究表明，對於胸骨傷口感染發生率高達14%的糖尿病患者，雙側乳內動脈（乳動脈）移植可能存在禁忌症[ 31 ]。圍手術期嚴格控制血糖以及在取血管過程中對乳內動脈進行骨骼化處理與較低的胸骨傷口感染率相關
In addition, the risk of sternal wound infection and kidney failure is higher in patients with diabetes [29-31]. It has been suggested that bilateral internal thoracic (mammary) artery grafting may be contraindicated in diabetic patients in whom the incidence of sternal wound infection is as high as 14 percent [31]. Maintenance of strict glycemic control during the perioperative period and skeletonization of the internal mammary artery during harvesting are associated with lower rates of sternal wound infection [32,33]. (See 'Intraoperative and postoperative glycemic control' below and "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Sternal wound infection and mediastinitis' and 'Internal thoracic artery grafts' below.)
儘管糖尿病似乎不會影響冠狀動脈繞道手術（CABG）後的院內死亡率，但糖尿病患者CABG術後的短期和長期存活率顯著降低。在多項大型觀察性研究中，與非糖尿病患者相比，糖尿病患者30天死亡率（5% vs. 2.5%）以及5年和10年死亡率（分別為22% vs. 12%和50% vs. 29%）均較高[ 29,30,34-42 ]。與死亡率類似，CABG術後非致命性不良冠狀動脈事件在糖尿病患者中也可能更為常見。一項納入超過12,000例患者的研究顯示，糖尿病與10年內免於經皮冠狀動脈介入治療（PCI）的比例顯著降低相關（83% vs. 86%），但在5年或10年內發生心肌梗塞或再次CABG的比例方面無差異[ 40 ]。另一項報告評估了在同一中心接受冠狀動脈旁路移植術 (CABG) 並進行過一次或多次重複血管造影的患者，並對他們進行了 ≥25 年的隨訪 [ 41 ]。糖尿病與動脈粥狀硬化進展或症狀復發的相對風險為 1.39 相關。
Although diabetes does not appear to affect in-hospital mortality after CABG, short- and long-term survival after CABG are significantly reduced in diabetic patients. In different large observational studies, compared with nondiabetic patients, patients with diabetes had higher mortality rates at 30 days (5 versus 2.5 percent) and at 5 and 10 years (22 versus 12 percent and 50 versus 29 percent, respectively) [29,30,34-42]. As with mortality, nonfatal adverse coronary outcomes after CABG also may be somewhat more common in diabetic patients. In a report of over 12,000 patients, diabetes was associated with a significantly lower rate of freedom from PCI at 10 years (83 versus 86 percent) but no difference in either MI or additional CABG at 5 or 10 years [40]. Another report evaluated 1615 patients who underwent CABG at a single center and had one or more repeat angiograms, and they were followed for ≥25 years [41]. Diabetes was associated with a relative risk of 1.39 for progression of atherosclerosis or recurrent symptoms.
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經皮冠狀動脈介入治療 (PCI) 與冠狀動脈旁路移植術 (CABG ) PCI versus CABG —
對於大多數患有糖尿病和複雜多支血管冠狀動脈疾病且需要血運重建的患者（參見上文「穩定型心絞痛的血運重建與藥物治療」），現有證據表明，冠狀動脈旁路移植術 (CABG) 可改善預後。這些證據來自 FREEDOM 試驗、BARI 2D 試驗中糖尿病患者的亞組分析（請參閱上文「穩定型心絞痛的血管重建與藥物治療」）以及 SYNTAX 試驗的亞組分析。
— For most patients with diabetes and complex multivessel CAD who require revascularization (see 'Revascularization versus medical therapy for stable angina' above), the evidence suggests outcomes are improved with coronary artery bypass graft surgery (CABG). The evidence comes from the FREEDOM trial and subgroup analysis of the BARI 2D trial of patients with diabetes and subgroup analyses of the SYNTAX trial.
在進行冠狀動脈血運重建之前，應向患者充分說明經皮冠狀動脈介入治療 (PCI) 和冠狀動脈繞道手術 (CABG) 的相對益處和成本。
Prior to coronary revascularization, the patient should have the relative benefits and costs of PCI and CABG fully described.
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左主幹冠狀動脈疾病且SYNTAX評分≤32－ 與非糖尿病患者類似，對於糖尿病患者，冠狀動脈繞道手術（CABG）或經皮冠狀動脈介入治療（PCI）可能是合理的血管重建方法。伴隨疾病的複雜程度等因素已被確定，有助於在兩者之間做出選擇。
EXCEL試驗將左主幹冠狀動脈顯著狹窄且SYNTAX評分低/中度（≤32）的患者隨機分組。所有患者均需符合經皮冠狀動脈介入治療（PCI）或冠狀動脈繞道手術（CABG）的適應症。 [ 2 ]（請參閱 「左主幹冠狀動脈疾病」部分的「隨機試驗」）。 EXCEL試驗共納入1905位患者（其中554例合併糖尿病），根據SYNTAX評分≤32，評估其冠狀動脈疾病複雜度為低或中度。 EXCEL試驗得出以下結論：
The EXCEL trial randomized patients with significant left main coronary artery stenosis and low/intermediate SYNTAX score (≤32). All patients had to be candidates for both PCI or CABG. [2] (see "Left main coronary artery disease", section on 'Randomized trials'). In EXCEL, there were 1905 patients (554 patients with diabetes) assessed to have low or intermediate CAD complexity based on a SYNTAX score ≤32. The following findings were noted in EXCEL:
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左主幹冠狀動脈疾病且SYNTAX評分≤32－ 與非糖尿病患者類似，對於糖尿病患者，冠狀動脈繞道手術（CABG）或經皮冠狀動脈介入治療（PCI）可能是合理的血管重建方法。伴隨疾病的複雜程度等因素已被確定，有助於在兩者之間做出選擇。
EXCEL試驗將左主幹冠狀動脈顯著狹窄且SYNTAX評分低/中度（≤32）的患者隨機分組。所有患者均需符合經皮冠狀動脈介入治療（PCI）或冠狀動脈繞道手術（CABG）的適應症。 [ 2 ]（請參閱 「左主幹冠狀動脈疾病」部分的「隨機試驗」）。 EXCEL試驗共納入1905位患者（其中554例合併糖尿病），根據SYNTAX評分≤32，評估其冠狀動脈疾病複雜度為低或中度。 EXCEL試驗得出以下結論：
The EXCEL trial randomized patients with significant left main coronary artery stenosis and low/intermediate SYNTAX score (≤32). All patients had to be candidates for both PCI or CABG. [2] (see "Left main coronary artery disease", section on 'Randomized trials'). In EXCEL, there were 1905 patients (554 patients with diabetes) assessed to have low or intermediate CAD complexity based on a SYNTAX score ≤32. The following findings were noted in EXCEL:
●三年複合主要終點（全因死亡、中風或心肌梗塞）在糖尿病患者中比非糖尿病患者更高（20.0% vs. 12.9%；風險比 [HR] 1.60，95% CI 1.26-2.04）。
●The three-year composite primary end point (all-cause death, stroke, or MI) was higher in patients with diabetes compared with those without (20.0 versus 12.9 percent; hazard ratio [HR] 1.60, 95% CI 1.26-2.04).
●在糖尿病患者中，接受 PCI 或 CABG 的患者的主要終點事件發生率相似（分別為 20.7% 和 19.3%；HR 1.03，95% CI 0.71-1.50）。
●In patients with diabetes, the rate of the primary end point was similar between those who received PCI or CABG (20.7 versus 19.3 percent, respectively; HR 1.03, 95% CI 0.71-1.50).
●接受經皮冠狀動脈介入治療（PCI）的患者全因死亡率較高（分別為13.6%和9.0%；p = 0.046），且糖尿病狀態與死亡率之間無顯著交互作用。然而，糖尿病亞組的總死亡人數僅為59例（PCI組38例，冠狀動脈繞道手術組21例），因此本研究樣本數不足以評估死亡為單一終點。
●The rate of all-cause death was higher in those treated with PCI (13.6 versus 9.0 percent, respectively; p = 0.046), and there was no significant interaction regarding diabetes status. However, there were only 59 total deaths in the subgroup with diabetes (n = 38 [PCI] versus n = 21 [CABG]), so the study was underpowered to evaluate death as a single endpoint.
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多支血管病變或複雜病變 Multivessel or complex disease — 在需要冠狀動脈血運重建的普通患者群體中，對於許多多支血管病變患者，冠狀動脈旁路移植術（CABG）優於經皮冠狀動脈介入治療（PCI）。對於非多支血管冠狀動脈病變的患者，複雜的解剖結構，例如左主幹遠端或左前降支近端狹窄，或迂曲血管中嚴重的鈣化病變，可能會影響CABG的決策。
In the general population of patients who require coronary revascularization, CABG is preferred to PCI in many patients with multivessel disease. In patients without multivessel coronary artery disease, complex anatomy such as distal left main or proximal left anterior descending coronary artery stenosis, or heavily calcified lesions in tortuous vessels, may influence decision-making in favor of CABG.
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FREEDOM試驗是迄今為止規模最大的相關隨機對照試驗，旨在評估經皮冠狀動脈介入治療（PCI）和冠狀動脈旁路移植術（CABG）在多支血管冠狀動脈疾病患者中的療效。在FREEDOM試驗中，1,900名患有糖尿病和多支血管冠狀動脈疾病（CAD）（83%為三支血管病變）的患者被隨機分配至接受早期藥物洗脫支架（DES）PCI治療組或CABG治療組。兩組患者均接受了最佳的心血管疾病二級預防藥物治療[ 43 ]。倖存者的中位追蹤時間為3.8年。研究結果如下：
The FREEDOM trial is the largest relevant randomized controlled trial evaluating PCI and CABG in patients with multivessel coronary artery disease. In the FREEDOM trial, 1900 patients with diabetes and multivessel CAD (83 percent three-vessel disease) were randomly assigned to either PCI with early generation drug-eluting stents (DES) or CABG. Both groups received optimal medical therapies for the secondary prevention of cardiovascular disease [43]. The median follow-up among survivors was 3.8 years. The following findings were noted:
●五年時，PCI組發生全因死亡、非致死性心肌梗塞或非致死性中風的主要複合終點事件的比例顯著高於CABG組（26.6% vs. 18.7%；絕對差值為7.9%，95% CI 3.3-12.5）。 CABG的益處在所有SYNTAX評分亞組中均存在。
●The primary composite outcome of death from any cause, nonfatal MI, or nonfatal stroke occurred significantly more often in the PCI group at five years (26.6 versus 18.7 percent; absolute difference of 7.9 percent, 95% CI 3.3-12.5). The benefit from CABG existed in all SYNTAX score subgroups.
●就複合終點的各個組成部分而言，PCI 組的全因死亡率和 MI 發生率顯著高於對照組（分別為 16.3% 對 10.9% 和 13.9% 對 6.0%），而中風發生率則顯著低於對照組（2.4% 對 5.2%）。
●With regard to the individual components of the composite end point, all-cause mortality and MI were significantly higher with PCI (16.3 versus 10.9 and 13.9 versus 6.0 percent, respectively), whereas stroke occurred significantly less often (2.4 versus 5.2 percent).
●一年後，PCI 組的再次血管重建率較高（12.6% vs. 4.8%；HR 2.74，95% CI 1.91-3.89）。
●At one year, there was a higher rate of repeat revascularization in the PCI group (12.6 versus 4.8 percent; HR 2.74, 95% CI 1.91-3.89).
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SYNTAX試驗比較了第一代藥物洗脫支架（DES）與冠狀動脈繞道手術（CABG）在多支血管冠狀動脈疾病患者的療效。本試驗將1800例三支血管或左主幹冠狀動脈疾病患者隨機分為紫杉醇洗脫支架組和CABG組。其中452例患者（25%）患有糖尿病。研究結果如下：
The SYNTAX trial compared first-generation DES with CABG in patients with multivessel coronary artery disease. In this trial, 1800 patients with three-vessel or left main coronary artery disease were randomized to paclitaxel-eluting stent or CABG. A total of 452 patients (25 percent) had diabetes. The following findings were noted:
In the general population of patients who require coronary revascularization, CABG is preferred to PCI in many patients with multivessel disease. In patients without multivessel coronary artery disease, complex anatomy such as distal left main or proximal left anterior descending coronary artery stenosis, or heavily calcified lesions in tortuous vessels, may influence decision-making in favor of CABG.
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FREEDOM試驗是迄今為止規模最大的相關隨機對照試驗，旨在評估經皮冠狀動脈介入治療（PCI）和冠狀動脈旁路移植術（CABG）在多支血管冠狀動脈疾病患者中的療效。在FREEDOM試驗中，1,900名患有糖尿病和多支血管冠狀動脈疾病（CAD）（83%為三支血管病變）的患者被隨機分配至接受早期藥物洗脫支架（DES）PCI治療組或CABG治療組。兩組患者均接受了最佳的心血管疾病二級預防藥物治療[ 43 ]。倖存者的中位追蹤時間為3.8年。研究結果如下：
The FREEDOM trial is the largest relevant randomized controlled trial evaluating PCI and CABG in patients with multivessel coronary artery disease. In the FREEDOM trial, 1900 patients with diabetes and multivessel CAD (83 percent three-vessel disease) were randomly assigned to either PCI with early generation drug-eluting stents (DES) or CABG. Both groups received optimal medical therapies for the secondary prevention of cardiovascular disease [43]. The median follow-up among survivors was 3.8 years. The following findings were noted:
●五年時，PCI組發生全因死亡、非致死性心肌梗塞或非致死性中風的主要複合終點事件的比例顯著高於CABG組（26.6% vs. 18.7%；絕對差值為7.9%，95% CI 3.3-12.5）。 CABG的益處在所有SYNTAX評分亞組中均存在。
●The primary composite outcome of death from any cause, nonfatal MI, or nonfatal stroke occurred significantly more often in the PCI group at five years (26.6 versus 18.7 percent; absolute difference of 7.9 percent, 95% CI 3.3-12.5). The benefit from CABG existed in all SYNTAX score subgroups.
●就複合終點的各個組成部分而言，PCI 組的全因死亡率和 MI 發生率顯著高於對照組（分別為 16.3% 對 10.9% 和 13.9% 對 6.0%），而中風發生率則顯著低於對照組（2.4% 對 5.2%）。
●With regard to the individual components of the composite end point, all-cause mortality and MI were significantly higher with PCI (16.3 versus 10.9 and 13.9 versus 6.0 percent, respectively), whereas stroke occurred significantly less often (2.4 versus 5.2 percent).
●一年後，PCI 組的再次血管重建率較高（12.6% vs. 4.8%；HR 2.74，95% CI 1.91-3.89）。
●At one year, there was a higher rate of repeat revascularization in the PCI group (12.6 versus 4.8 percent; HR 2.74, 95% CI 1.91-3.89).
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SYNTAX試驗比較了第一代藥物洗脫支架（DES）與冠狀動脈繞道手術（CABG）在多支血管冠狀動脈疾病患者的療效。本試驗將1800例三支血管或左主幹冠狀動脈疾病患者隨機分為紫杉醇洗脫支架組和CABG組。其中452例患者（25%）患有糖尿病。研究結果如下：
The SYNTAX trial compared first-generation DES with CABG in patients with multivessel coronary artery disease. In this trial, 1800 patients with three-vessel or left main coronary artery disease were randomized to paclitaxel-eluting stent or CABG. A total of 452 patients (25 percent) had diabetes. The following findings were noted:
●在12個月的整體試驗組中，PCI組的主要不良心腦血管事件發生率高於CABG組（17.8% [PCI] vs. 12.4% [CABG]；p = 0.002）。糖尿病亞組的結果也一致。
●In the overall trial cohort at 12 months, major adverse cardiac or cerebrovascular events were higher in the PCI group (17.8 percent [PCI] versus 12.4 percent [CABG]; p = 0.002). The results were consistent in the subgroup with diabetes.
●三年後，在糖尿病患者群組中，PCI組的主要不良心腦血管事件發生率高於CABG組（37% [PCI] vs. 22.9% [CABG]；p = 0.002）。接受PCI治療的糖尿病患者再次血管重建的需求也顯著高於CABG組（28% [PCI] vs. 12.9% [CABG]；p<0.001）[ 44 ]。
●At three years, in the cohort with diabetes, major adverse cardiac and cerebrovascular event rates were higher with PCI (37 percent [PCI] versus 22.9 percent [CABG]; p = 0.002). The need for repeat revascularization was significantly higher in patients with diabetes treated with PCI (28 percent [PCI] versus 12.9 percent [CABG]; p<0.001) [44].
●10 年時，接受 PCI 治療的患者與接受 CABG 治療的患者相比，死亡率無顯著差異（PCI 組 27% [n = 244] vs. CABG 組 24% [n = 211]；p = 0.09）。在糖尿病患者群組中，452 例患者獲得了 10 年追蹤結果，其中共有 150 例死亡。接受 PCI 治療的患者與接受 CABG 治療的患者相比，10 年死亡風險無差異（HR 1.10；95% CI 0.80-1.52）[ 5 ]。
●At 10 years, there were no significant differences in death between patients treated with PCI compared with CABG (27 percent [n = 244 with PCI] versus 24 percent [n = 211 with CABG]; p = 0.09). In the cohort with diabetes, in whom 10-year outcomes were available in 452, a total of 150 had died. There were no differences in the risk of death at 10 years in patients treated with PCI compared with CABG (HR 1.10; 95% CI 0.80-1.52) [5].
應理解，本試驗中使用的 DES（紫杉醇洗脫劑）已被證明療效較差，不如當前一代的 DES。
These data should be interpreted with the understanding that the DES used in this trial (paclitaxel-eluting) has been shown to be less effective and inferior to the current generation of DES.
一項納入 11 項隨機試驗數據的患者層級統合分析評估了 PCI 和 CABG，為 CABG 對糖尿病和多支冠狀動脈疾病患者的優越性提供了更多證據 [ 4 ]。
A patient-level meta-analysis that included data from 11 randomized trials evaluating PCI and CABG provides additional evidence for the superiority of CABG for patients with diabetes and multivessel coronary artery disease [4].
●與 CABG 相比，PCI 治療糖尿病和多支冠狀動脈疾病患者的五年死亡率明顯較高（15.5% vs. 10.0%；HR 1.48；95% CI 1.019-1.84；p = 0.0004）。
●Mortality at five years was significantly higher with PCI in those patients with diabetes and multivessel coronary artery disease compared with CABG (15.5 versus 10.0 percent; HR 1.48; 95% CI 1.019-1.84; p = 0.0004).
●在非糖尿病的多支血管病變患者中，經皮冠狀動脈介入治療（PCI）和冠狀動脈繞道手術（CABG）的死亡率無差異（HR 1.08；95% CI 0.86-1.36；p = 0.49）。
●There was no difference in mortality between PCI and CABG in patients with multivessel without diabetes (HR 1.08; 95% CI 0.86-1.36; p = 0.49).
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單支或雙支血管病變 －
對於單支血管或非複雜病變且需要血管重建的患者，經皮冠狀動脈介入治療（PCI）是合理的選擇。雖然這個問題尚未得到專門研究，但我們的大多數專家更傾向於PCI而非冠狀動脈繞道手術（CABG）。
One- or two-vessel disease — For patients with single-vessel or noncomplex disease for whom revascularization is indicated, PCI is a reasonable choice. While this issue has not been specifically studied, most of our experts prefer PCI to CABG.
既往冠狀動脈繞道手術 － 對於糖尿病患者術後出現心絞痛，最佳血管重建方案尚不清楚。
Previous coronary artery bypass graft surgery — The optimal revascularization approach in diabetic patients with post-CABG angina is not known. The general approach to the management of post-CABG angina is discussed separately.
對於大多數患有糖尿病且在冠狀動脈旁路移植術（CABG）後出現難以忍受的心絞痛（且解剖結構合適）的患者，經皮冠狀動脈介入治療（PCI）是合理的首選方案。對於多支血管移植失敗或先前未接受過左側內乳動脈移植的患者，可以考慮再次進行CABG。
PCI is a reasonable first choice for most patients with diabetes and unacceptable angina (with appropriate anatomy) after CABG. Repeat CABG can be considered for patients with multigraft failure or no prior placement of a left internal thoracic artery graft.
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Previous coronary artery bypass graft surgery — The optimal revascularization approach in diabetic patients with post-CABG angina is not known. The general approach to the management of post-CABG angina is discussed separately.
對於大多數患有糖尿病且在冠狀動脈旁路移植術（CABG）後出現難以忍受的心絞痛（且解剖結構合適）的患者，經皮冠狀動脈介入治療（PCI）是合理的首選方案。對於多支血管移植失敗或先前未接受過左側內乳動脈移植的患者，可以考慮再次進行CABG。
PCI is a reasonable first choice for most patients with diabetes and unacceptable angina (with appropriate anatomy) after CABG. Repeat CABG can be considered for patients with multigraft failure or no prior placement of a left internal thoracic artery graft.
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PCI的考量 PCI CONSIDERATIONS
對於接受經皮冠狀動脈介入治療 (PCI) 的糖尿病患者，標靶病變血管重建率、心肌梗塞發生率或存活率等結果可能受到支架類型以及糖尿病相關因素的影響。
Among patients with diabetes who undergo percutaneous coronary intervention (PCI), outcomes such as the rates of target lesion revascularization, MI, or survival may be influenced by the stent type as well as diabetes-related factors.
對於接受經皮冠狀動脈介入治療 (PCI) 的糖尿病患者，標靶病變血管重建率、心肌梗塞發生率或存活率等結果可能受到支架類型以及糖尿病相關因素的影響。
Among patients with diabetes who undergo percutaneous coronary intervention (PCI), outcomes such as the rates of target lesion revascularization, MI, or survival may be influenced by the stent type as well as diabetes-related factors.
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支架類型 Stent type —
與接受經皮冠狀動脈介入治療（PCI）並植入支架的一般患者族群類似，接受目前一代藥物洗脫支架（DES）的患者，其再狹窄率和後續血運重建率低於接受裸金屬支架或早期DES的患者[ 45-58 ]。最新一代超細支架可能降低目標病變失敗和心肌梗塞（MI）的發生率[ 59 ]。然而，一項針對糖尿病患者使用超細支架的患者層級統合分析並未顯示其具有更高的益處
Similar to the general population of patients who undergo PCI with stent placement, patients who receive current generation drug-eluting stents (DES) have a lower rate of restenosis and subsequent revascularization than those who receive either bare metal stents or early generation DES [45-58]. The newest generation of ultra-thin-strut stents may reduce target lesion failure and MI [59]. However, a patient-level meta-analysis of ultra-thin stents in patients with diabetes did not demonstrate increased benefit [60].
糖尿病相關因素 Diabetes-related factors —
Several diabetes-related clinical factors have been evaluated for their impact on outcome after PCI:
糖尿病患者經皮冠狀動脈介入治療（PCI）後，血糖值較低時，再狹窄率可能較低。一項2004年發表的分析提示了這一觀點，該分析納入了239例擇期PCI患者（其中179例為糖尿病患者，67%的患者接受了支架植入術），並在術前測量了糖化血紅蛋白（HbA1c）水平[ 61 ]。術前HbA1c≤7%的糖尿病患者，其12個月時的標靶血管血管重建率與非糖尿病患者相當（15% vs 18%），而HbA1c>7%的糖尿病患者的標靶血管血管重建率則顯著升高（34%）。然而，由於研究為非隨機觀察性研究，樣本量較小，且可能存在混雜因素，因此其結果的普遍適用性受到限制。
●The rate of restenosis after PCI in diabetic patients may be lower in the setting of lower glycemia. This was suggested in an analysis from 2004 of 239 patients (179 with diabetes) who underwent elective PCI (67 percent with stenting) after measurement of glycated hemoglobin (HbA1c) [61]. Diabetic patients with a preprocedural HbA1c ≤7 percent had a rate of target vessel revascularization at 12 months that was comparable to that in nondiabetic patients (15 versus 18 percent), while diabetic patients with an HbA1c >7 percent had a significantly higher rate of target vessel revascularization (34 percent). Generalization is limited by the study design (non-randomized observational study), its small size, and potential for confounding.
The potential efficacy of this approach has been evaluated in two small randomized trials in which patients with type 2 diabetes who underwent PCI with stenting were randomly assigned to either a thiazolidinedione (pioglitazone or rosiglitazone) or placebo [62,63]. In both studies, the rate of angiographic restenosis was significantly lower in the thiazolidinedione group. Further studies are required to confirm the efficacy and safety of this approach, particularly with the use of DES since stent technology has evolved since the conduct of these studies.
血脂相關因素Lipid-related factors —
降血脂治療是PCI術後患者二級預防措施的基石，旨在降低未來冠狀動脈事件的風險。
Lipid-lowering therapy is the cornerstone of secondary prevention measures to reduce future coronary events in patients following PCI.
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冠狀動脈繞道術的考量 CORONARY ARTERY BYPASS GRAFT SURGERY CONSIDERATIONS共病症 Comorbidities —
與非糖尿病患者相比，糖尿病患者在冠狀動脈繞道手術（CABG）後長期死亡率和非致命性不良事件發生率較高。
The rates of long-term death and adverse nonfatal outcomes after coronary artery bypass graft surgery (CABG) are higher in patients with diabetes compared with those without diabetes. (See 'Outcomes' above.)
與非糖尿病患者相比，糖尿病患者在冠狀動脈繞道手術（CABG）後長期死亡率和非致命性不良事件發生率較高。
The rates of long-term death and adverse nonfatal outcomes after coronary artery bypass graft surgery (CABG) are higher in patients with diabetes compared with those without diabetes. (See 'Outcomes' above.)
多種因素導致預後不良。接受 CABG 手術的糖尿病患者的風險狀況較差，往往年齡較大，三個血管病變較多，左心室射血分數 (LVEF) 低於非糖尿病患者 [ 34,36,39,64 ]。
A variety of factors contribute to the worse prognosis. Diabetic patients who undergo CABG have a worse risk profile, tending to be older with more three-vessel disease and lower LVEF than nondiabetic patients [34,36,39,64].
糖尿病合併症會影響冠狀動脈繞道手術（CABG）後的存活率。一項納入1992年至2001年間接受單純CABG手術的36,641例患者的研究證實了這一點：70%的患者無糖尿病，22%的患者患有糖尿病但無腎衰竭（無需術前透析）或血管疾病（外周血管或腦血管），8%的患者患有糖尿病並伴有腎功能衰竭（無需術前透析）或血管疾病（外周血管或腦血管），8%的患者患有糖尿病並伴有腎功能衰竭和血管疾病[ 65 ]。無糖尿病患者的年死亡率（3.1%）與患有糖尿病但無腎衰竭或血管疾病的患者（4.4%）相似。而患有糖尿病並伴隨腎衰竭和/或血管疾病的患者的年死亡率則顯著較高（9.4%）。
Comorbidities of diabetes influence post-CABG survival. This was illustrated in a cohort of 36,641 patients undergoing isolated CABG between 1992 and 2001: 70 percent did not have diabetes, 22 percent had diabetes without kidney failure (requiring preoperative dialysis) or vascular disease (peripheral or cerebrovascular), and 8 percent had diabetes with kidney failure and/or vascular disease [65]. The annual mortality rate for patients without diabetes (3.1 percent) was similar to that for patients with diabetes but no kidney failure or vascular disease (4.4 percent). Patients with diabetes who had kidney failure and/or vascular disease had a significantly higher annual mortality rate (9.4 percent).
另一項針對 905 例患者進行的觀察性研究發現（多因子分析），血清肌酸酐升高（而非先前研究中的腎衰竭）是五年死亡率的獨立預測因子（調整後的風險比為 1.5）[ 66 ]。蛋白尿也是死亡率的獨立預測因子。
Another observational study of 905 patients found (on multivariate analysis) that an elevated serum creatinine (not kidney failure as in the prior study) was an independent predictor of five-year mortality (adjusted hazard ratio 1.5) [66]. Proteinuria was also an independent predictor of mortality.
術前血糖控制與冠狀動脈繞道手術（CABG）的預後有關。在2002年至2006年間，一家學術醫療中心連續納入3555例擇期CABG患者，結果顯示HbA1c升高與死亡、心肌梗塞和深部胸骨傷口感染風險增加相關[ 67 ]。校正潛在混雜因子後，HbA1c每升高1%，死亡風險增加（比值比1.40；95% CI 1.06-1.86）。
Preoperative glycemic control is associated with outcomes following CABG. In 3555 consecutive patients undergoing elective CABG at an academic medical center between 2002 and 2006, increasing HbA1c was associated with increased risk of mortality, MI, and deep sternal wound infection [67]. After adjusting for potential confounders, there was an increased risk of mortality (odds ratio 1.40; 95% CI 1.06-1.86) for every 1 percent increase in HbA1c.
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內乳動脈移植 － 所有接受冠狀動脈繞道手術（CABG）的患者，包括糖尿病患者，都應接受內乳（乳內）動脈（ITA）移植，以提高存活率。
Internal thoracic artery grafts — All patients undergoing CABG, including those with diabetes, should receive an internal thoracic (mammary) artery (ITA) graft to improve survival.
此外，基於兩項觀察性研究，我們傾向於對許多醣尿病患者採用雙側乳內動脈（ITA）移植而非單側ITA移植。儘管與單側ITA移植相比，雙側ITA移植可能會略微增加胸骨傷口感染率，且糖尿病可能是術後縱膈炎的危險因子[ 68,69 ]，但我們仍提出此項建議。
In addition, we prefer bilateral to single ITA grafting for many patients with diabetes based on two observational studies. This recommendation is made despite the fact that the rate of sternal wound infection may be modestly increased with bilateral compared with single ITA grafting and that diabetes may be a risk factor for the development of postoperative mediastinitis [68,69].
一項納入1107例連續糖尿病患者的研究評估了雙側內乳動脈（ITA）移植與單側ITA移植相比是否能改善患者預後[ 70 ]。這些患者分別接受了單側或雙側ITA移植。經傾向性配對後，研究人員建立了兩個隊列，每個隊列包含414名患者。單側ITA組和雙側ITA組在手術死亡率（分別為2.4%和3.1%）、胸骨傷口感染率（分別為1.7%和3.1%）或總併發症發生率（17.1%）方面均無顯著差異。然而，單側ITA移植組的長期中位存活期顯著低於雙側ITA組（分別為9.8年和13.1年）。另一項2012年的觀察性研究[ 71 ]也報告了糖尿病患者接受雙側ITA移植後長期存活率的類似改善。
The issue of whether bilateral ITA improves outcomes compared with single ITA in patients with diabetes was evaluated in a study of 1107 consecutive patients who received either a single or bilateral ITA [70]. After propensity matching, two cohorts of 414 individuals were created. There was no significant difference between the single and bilateral ITA groups in operative mortality (2.4 versus 3.1 percent, respectively), sternal wound infection (1.7 versus 3.1 percent), or total complications (17.1 percent). However, late median survival was significantly lower with single ITA grafting (9.8 versus 13.1 years). Similar improvement in long-term survival after placement of bilateral ITA among patients with diabetes was reported in another 2012 observational study [71].
對於接受冠狀動脈繞道手術（CABG）的患者，尤其是相對年輕的糖尿病患者，應考慮使用橈動脈移植。一項納入六項試驗的統合分析評估了橈動脈移植在接受CABG手術患者中的應用（平均年齡67歲，35%患有糖尿病），結果顯示，與大隱靜脈移植相比，橈動脈移植可降低死亡、心肌梗塞或再次血管重建的發生率（風險比[HR] 0.67，95% CI 0.49-0.72 ] 。橈動脈移植的移植失敗風險也較低（HR 0.44；95% CI 0.28-0.70）。糖尿病患者和非糖尿病患者的預後相似。
Radial grafts should be considered in patients undergoing CABG, particularly in those patients with diabetes who are relatively young. In a meta-analysis of six trials evaluating the use of radial artery grafts in patients undergoing CABG (mean age 67 and 35 percent with diabetes), the use of radial grafts reduced the rate of death, MI, or revascularization when compared with saphenous vein grafts (hazard ratio [HR] 0.67, 95% CI 0.49-0.90) [72]. Radial arterial grafts were also at lower risk of graft failure (HR 0.44; 95% CI 0.28-0.70). Outcomes were similar in patients with and without diabetes.
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術中及術後血糖控制 Intraoperative and postoperative glycemic control —
對於大多數糖尿病患者，我們嘗試在術中及術後進行強化血糖控制，以改善冠狀動脈繞道手術（CABG）後糖尿病患者的心臟和非心臟預後[ 32,73,74 ]。以下觀察結果說明了研究結果的範圍：
For most patients with diabetes, we attempt intensive glycemic control intra- and postoperatively to improve both cardiac and noncardiac outcomes in diabetic patients after CABG [32,73,74]. The following observations illustrate the range of findings:
●在一項前瞻性試驗中，141例接受冠狀動脈繞道手術（CABG）的糖尿病患者被隨機分配至兩組：一組接受葡萄糖-胰島素-鉀（GIK）輸注以嚴格控制血糖（125至200 mg/dL [6.9至11.1 mmol/L]），另一組接受間歇性皮下注射胰島素的標準治療[ 74,75 ]。接受GIK治療的患者在圍手術期平均血清葡萄糖濃度較低（138 mg/dL vs. 260 mg/dL [7.7 mmol/L vs. 14.4 mmol/L]）。兩年後，GIK組患者的傷口感染率（1% vs. 10%）、復發性缺血發生率（5% vs. 19%）和死亡率（2% vs. 10%）均顯著低於對照組。
●In a prospective trial, 141 patients with diabetes who were undergoing CABG were randomly assigned to tight glycemic control (125 to 200 mg/dL [6.9 to 11.1 mmol/L]) with a glucose-insulin-potassium (GIK) infusion or standard therapy with intermittent subcutaneous insulin [74,75]. Patients treated with GIK had lower mean serum glucose concentrations in the perioperative period (138 versus 260 mg/dL [7.7 versus 14.4 mg/dL]). At two years, GIK patients had significantly lower rates of wound infections (1 versus 10 percent), recurrent ischemia (5 versus 19 percent), and mortality (2 versus 10 percent).
●在一項隨機試驗[ 76 ]中，352例接受冠狀動脈繞道手術（CABG）的患者（無論是否已知糖尿病）被隨機分配至強化血糖控制組（血糖目標值100至140 mg/dL）或保守血糖控制組（血糖目標值141至180 mg/dL）。在糖尿病患者群中，強化組和保守組患者的併發症發生率並無顯著差異（分別為49%和48%，p = 0.87）。
●In a randomized trial [76], 352 patients (with or without known diabetes) undergoing CABG were randomized to intensive glucose target (100 to 140 mg/dL) or to a conservative target (141 to 180 mg/dL). In the cohort with diabetes, there were no differences in the rates of complications in patients treated in the intensive or conservative group (49 versus 48 percent, p = 0.87).
RECOMMENDATIONS OF OTHERS
A variety of factors contribute to the worse prognosis. Diabetic patients who undergo CABG have a worse risk profile, tending to be older with more three-vessel disease and lower LVEF than nondiabetic patients [34,36,39,64].
糖尿病合併症會影響冠狀動脈繞道手術（CABG）後的存活率。一項納入1992年至2001年間接受單純CABG手術的36,641例患者的研究證實了這一點：70%的患者無糖尿病，22%的患者患有糖尿病但無腎衰竭（無需術前透析）或血管疾病（外周血管或腦血管），8%的患者患有糖尿病並伴有腎功能衰竭（無需術前透析）或血管疾病（外周血管或腦血管），8%的患者患有糖尿病並伴有腎功能衰竭和血管疾病[ 65 ]。無糖尿病患者的年死亡率（3.1%）與患有糖尿病但無腎衰竭或血管疾病的患者（4.4%）相似。而患有糖尿病並伴隨腎衰竭和/或血管疾病的患者的年死亡率則顯著較高（9.4%）。
Comorbidities of diabetes influence post-CABG survival. This was illustrated in a cohort of 36,641 patients undergoing isolated CABG between 1992 and 2001: 70 percent did not have diabetes, 22 percent had diabetes without kidney failure (requiring preoperative dialysis) or vascular disease (peripheral or cerebrovascular), and 8 percent had diabetes with kidney failure and/or vascular disease [65]. The annual mortality rate for patients without diabetes (3.1 percent) was similar to that for patients with diabetes but no kidney failure or vascular disease (4.4 percent). Patients with diabetes who had kidney failure and/or vascular disease had a significantly higher annual mortality rate (9.4 percent).
另一項針對 905 例患者進行的觀察性研究發現（多因子分析），血清肌酸酐升高（而非先前研究中的腎衰竭）是五年死亡率的獨立預測因子（調整後的風險比為 1.5）[ 66 ]。蛋白尿也是死亡率的獨立預測因子。
Another observational study of 905 patients found (on multivariate analysis) that an elevated serum creatinine (not kidney failure as in the prior study) was an independent predictor of five-year mortality (adjusted hazard ratio 1.5) [66]. Proteinuria was also an independent predictor of mortality.
術前血糖控制與冠狀動脈繞道手術（CABG）的預後有關。在2002年至2006年間，一家學術醫療中心連續納入3555例擇期CABG患者，結果顯示HbA1c升高與死亡、心肌梗塞和深部胸骨傷口感染風險增加相關[ 67 ]。校正潛在混雜因子後，HbA1c每升高1%，死亡風險增加（比值比1.40；95% CI 1.06-1.86）。
Preoperative glycemic control is associated with outcomes following CABG. In 3555 consecutive patients undergoing elective CABG at an academic medical center between 2002 and 2006, increasing HbA1c was associated with increased risk of mortality, MI, and deep sternal wound infection [67]. After adjusting for potential confounders, there was an increased risk of mortality (odds ratio 1.40; 95% CI 1.06-1.86) for every 1 percent increase in HbA1c.
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內乳動脈移植 － 所有接受冠狀動脈繞道手術（CABG）的患者，包括糖尿病患者，都應接受內乳（乳內）動脈（ITA）移植，以提高存活率。
Internal thoracic artery grafts — All patients undergoing CABG, including those with diabetes, should receive an internal thoracic (mammary) artery (ITA) graft to improve survival.
此外，基於兩項觀察性研究，我們傾向於對許多醣尿病患者採用雙側乳內動脈（ITA）移植而非單側ITA移植。儘管與單側ITA移植相比，雙側ITA移植可能會略微增加胸骨傷口感染率，且糖尿病可能是術後縱膈炎的危險因子[ 68,69 ]，但我們仍提出此項建議。
In addition, we prefer bilateral to single ITA grafting for many patients with diabetes based on two observational studies. This recommendation is made despite the fact that the rate of sternal wound infection may be modestly increased with bilateral compared with single ITA grafting and that diabetes may be a risk factor for the development of postoperative mediastinitis [68,69].
一項納入1107例連續糖尿病患者的研究評估了雙側內乳動脈（ITA）移植與單側ITA移植相比是否能改善患者預後[ 70 ]。這些患者分別接受了單側或雙側ITA移植。經傾向性配對後，研究人員建立了兩個隊列，每個隊列包含414名患者。單側ITA組和雙側ITA組在手術死亡率（分別為2.4%和3.1%）、胸骨傷口感染率（分別為1.7%和3.1%）或總併發症發生率（17.1%）方面均無顯著差異。然而，單側ITA移植組的長期中位存活期顯著低於雙側ITA組（分別為9.8年和13.1年）。另一項2012年的觀察性研究[ 71 ]也報告了糖尿病患者接受雙側ITA移植後長期存活率的類似改善。
The issue of whether bilateral ITA improves outcomes compared with single ITA in patients with diabetes was evaluated in a study of 1107 consecutive patients who received either a single or bilateral ITA [70]. After propensity matching, two cohorts of 414 individuals were created. There was no significant difference between the single and bilateral ITA groups in operative mortality (2.4 versus 3.1 percent, respectively), sternal wound infection (1.7 versus 3.1 percent), or total complications (17.1 percent). However, late median survival was significantly lower with single ITA grafting (9.8 versus 13.1 years). Similar improvement in long-term survival after placement of bilateral ITA among patients with diabetes was reported in another 2012 observational study [71].
對於接受冠狀動脈繞道手術（CABG）的患者，尤其是相對年輕的糖尿病患者，應考慮使用橈動脈移植。一項納入六項試驗的統合分析評估了橈動脈移植在接受CABG手術患者中的應用（平均年齡67歲，35%患有糖尿病），結果顯示，與大隱靜脈移植相比，橈動脈移植可降低死亡、心肌梗塞或再次血管重建的發生率（風險比[HR] 0.67，95% CI 0.49-0.72 ] 。橈動脈移植的移植失敗風險也較低（HR 0.44；95% CI 0.28-0.70）。糖尿病患者和非糖尿病患者的預後相似。
Radial grafts should be considered in patients undergoing CABG, particularly in those patients with diabetes who are relatively young. In a meta-analysis of six trials evaluating the use of radial artery grafts in patients undergoing CABG (mean age 67 and 35 percent with diabetes), the use of radial grafts reduced the rate of death, MI, or revascularization when compared with saphenous vein grafts (hazard ratio [HR] 0.67, 95% CI 0.49-0.90) [72]. Radial arterial grafts were also at lower risk of graft failure (HR 0.44; 95% CI 0.28-0.70). Outcomes were similar in patients with and without diabetes.
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術中及術後血糖控制 Intraoperative and postoperative glycemic control —
對於大多數糖尿病患者，我們嘗試在術中及術後進行強化血糖控制，以改善冠狀動脈繞道手術（CABG）後糖尿病患者的心臟和非心臟預後[ 32,73,74 ]。以下觀察結果說明了研究結果的範圍：
For most patients with diabetes, we attempt intensive glycemic control intra- and postoperatively to improve both cardiac and noncardiac outcomes in diabetic patients after CABG [32,73,74]. The following observations illustrate the range of findings:
●在一項前瞻性試驗中，141例接受冠狀動脈繞道手術（CABG）的糖尿病患者被隨機分配至兩組：一組接受葡萄糖-胰島素-鉀（GIK）輸注以嚴格控制血糖（125至200 mg/dL [6.9至11.1 mmol/L]），另一組接受間歇性皮下注射胰島素的標準治療[ 74,75 ]。接受GIK治療的患者在圍手術期平均血清葡萄糖濃度較低（138 mg/dL vs. 260 mg/dL [7.7 mmol/L vs. 14.4 mmol/L]）。兩年後，GIK組患者的傷口感染率（1% vs. 10%）、復發性缺血發生率（5% vs. 19%）和死亡率（2% vs. 10%）均顯著低於對照組。
●In a prospective trial, 141 patients with diabetes who were undergoing CABG were randomly assigned to tight glycemic control (125 to 200 mg/dL [6.9 to 11.1 mmol/L]) with a glucose-insulin-potassium (GIK) infusion or standard therapy with intermittent subcutaneous insulin [74,75]. Patients treated with GIK had lower mean serum glucose concentrations in the perioperative period (138 versus 260 mg/dL [7.7 versus 14.4 mg/dL]). At two years, GIK patients had significantly lower rates of wound infections (1 versus 10 percent), recurrent ischemia (5 versus 19 percent), and mortality (2 versus 10 percent).
●在一項隨機試驗[ 76 ]中，352例接受冠狀動脈繞道手術（CABG）的患者（無論是否已知糖尿病）被隨機分配至強化血糖控制組（血糖目標值100至140 mg/dL）或保守血糖控制組（血糖目標值141至180 mg/dL）。在糖尿病患者群中，強化組和保守組患者的併發症發生率並無顯著差異（分別為49%和48%，p = 0.87）。
●In a randomized trial [76], 352 patients (with or without known diabetes) undergoing CABG were randomized to intensive glucose target (100 to 140 mg/dL) or to a conservative target (141 to 180 mg/dL). In the cohort with diabetes, there were no differences in the rates of complications in patients treated in the intensive or conservative group (49 versus 48 percent, p = 0.87).
RECOMMENDATIONS OF OTHERS
這篇的建議與各學會 ACCF/AHA/AATS/PCNA/SCAI/STSCAI/STS 提出的建議相同
Our recommendations are similar to those from the American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society for Cardiovascular Angiography and Interventions/Society of Thoracic Surgeons in 2014 and those from the European Society of Cardiology/European Association for the Study of Diabetes in 2013
Our recommendations are similar to those from the American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society for Cardiovascular Angiography and Interventions/Society of Thoracic Surgeons in 2014 and those from the European Society of Cardiology/European Association for the Study of Diabetes in 2013
底下是沒有去除格式之前的原文
SUMMARY AND RECOMMENDATIONS
●Indications – The indications for revascularization in stable patients are similar for those with and without diabetes. (See 'Indications for revascularization' above.)
●Our approach to revascularization – For patients with diabetes and stable angina who do not have a clear indication for revascularization, we suggest intensive medical therapy as the initial strategy rather than immediate revascularization (Grade 2B). (See 'Revascularization versus medical therapy for stable angina' above.)
For patients with diabetes and multivessel disease (particularly if it is complex) who require revascularization, we recommend CABG rather than percutaneous coronary intervention (PCI) (Grade 1B). (See 'PCI versus CABG' above.)
For patients with diabetes undergoing CABG, we suggest placement of bilateral, rather than single, internal thoracic artery (ITA) grafts (Grade 2C). It is reasonable to not perform bilateral ITA grafting in individuals older than 70 to 75 years, as the survival benefit from bilateral ITA may be small in older individuals. (See 'Internal thoracic artery grafts' above.)
For patients with diabetes who have recurrence of unacceptable angina after CABG, we suggest repeat revascularization with PCI for appropriate lesions (Grade 2C). (See 'Previous coronary artery bypass graft surgery' above.)
For patients with diabetes who undergo CABG, we suggest tight glycemic control intra- and postoperatively to improve both cardiac and noncardiac outcomes (Grade 2C).
INDICATIONS FOR REVASCULARIZATION
We believe that the indications for revascularization in stable patients are similar for those with and without diabetes. The decision to proceed with revascularization, as opposed to continuing medical therapy, is made in three groups:
●Patients with activity-limiting symptoms despite maximum medical therapy.
●Active patients who want revascularization for improved quality of life compared with medical therapy, such as those who are not tolerating medical therapy or want to increase their activity level.
●Patients with anatomy for which revascularization has a proven survival benefit, such as significant left main coronary artery disease (CAD; greater than 50 percent luminal narrowing) or multivessel CAD with a reduction of left ventricular ejection fraction (LVEF) and a large area of potentially ischemic myocardium.
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OUR APPROACH TO REVASCULARIZATION
For most patients with diabetes who have multivessel or complex disease and indications for revascularization (see 'Indications for revascularization' above), coronary artery bypass graft surgery (CABG) is preferable to percutaneous coronary intervention (PCI). This preference is based on the results of randomized clinical trials. The FREEDOM trial found that outcomes were improved with CABG. These findings are consistent with the SYNergy Between PCI With TAXus and Cardiac Surgery (SYNTAX) trial and a patient-level meta-analysis [4,5]. For patients with low SYNTAX score, single-, or two-vessel disease who have lesions that are focal and amenable to PCI, we believe that PCI is a reasonable alternative. In patients with three-vessel disease and a low SYNTAX score, it is not unreasonable to consider PCI, particularly for those with focal stenoses and increased surgical risk.
Regardless of the procedure chosen, all patients with diabetes and CAD should be treated with aggressive risk factor reduction, including optimal management of diabetes, blood pressure control, aspirin, lipid lowering therapy, and lifestyle changes including exercise, dietary modifications, and smoking cessation when indicated.
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OUTCOMES
Patients with diabetes comprise over 30 percent of those who undergo revascularization, consistent with the approximately 10 percent prevalence of diabetes in the general population and their two- to threefold increased risk for cardiovascular disease compared with the nondiabetic population. Procedural success is similar in the two groups, but long-term outcomes after revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) are worse in diabetic compared with nondiabetic patients which may reflect the burden of comorbidities in patients with diabetes [2].
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Revascularization versus medical therapy for stable angina — In the broad population of patients with diabetes, risk of death and future myocardial infarction are similar between revascularization and optimal medical therapy [6-9]. Patients at high angiographic or clinical risk may benefit from revascularization [10].
The best available evidence regarding a comparison of revascularization and optimal medical therapy comes from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI) 2D trial [6,7]. In BARI 2D, 2368 patients with type 2 diabetes mellitus and nonacute ischemic heart disease (defined as either a ≥50 percent stenosis of a major epicardial coronary artery associated with a positive stress test or ≥70 percent stenosis and classic angina) were randomly assigned to either prompt revascularization (PCI or CABG) plus medical therapy or medical therapy only. The most appropriate mode of revascularization (PCI or CABG) was determined by the investigator prior to randomization. At five years, the primary end points of the rates of survival or freedom from major cardiovascular events (eg, death, myocardial infarction [MI], or stroke) did not differ significantly between the prompt revascularization group and the intensive medical therapy alone group (88.3 versus 87.8 percent and 77.2 versus 75.9 percent, respectively). However, in subgroup analysis, the rate of freedom from major cardiovascular events was significantly higher with CABG (77.6 versus 69.5 percent), predominantly attributable to a reduction in nonfatal MI. In the PCI stratum, there were no differences in major adverse cardiovascular events with prompt revascularization, when compared with intensive medical therapy alone (77.0 versus 78.9 percent).
In the COURAGE trial, an initial revascularization strategy with PCI did not reduce the risk of death or MI when compared with an initial trial of medical therapy in a broad group of patients . However, patients treated with initial revascularization were more likely to be free from angina at one year (66 versus 58 percent). In the subgroup of patients with diabetes (n=766), patients treated with initial medical therapy had similar cardiovascular outcomes as patients treated with revascularization (HR 0.99; 95% CI 0.73-1.32) [8,9].
In the ISCHEMIA trial, patients with chronic coronary disease were randomly assigned to an invasive (medical therapy plus angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). In this study, 43 percent of participants had diabetes. In a diabetes substudy of ISCHEMIA, participants with diabetes had increased hazards for death or MI over a median 3.1 years of follow-up (HR 1.49; 95% CI 1.31-1.70) [11]. However, there was no difference in death or MI according to initial invasive strategy versus medical therapy. Similarly, in the REVIVED-SCIS2 trial of patients without angina who had left ventricular dysfunction with evidence of myocardial viability, 41 percent had diabetes [12]. In this study, patients who had revascularization with percutaneous coronary intervention compared with medical therapy had similar risks of death or hospitalization for heart failure.
In an attempt to understand further which patients might benefit from CABG, the BARI 2D investigators developed a risk score from baseline angiographic (myocardial jeopardy index, total number of coronary lesions, prior coronary revascularization, and LVEF) and clinical variables (Framingham Risk Score) [10]. Patients were then stratified into high- and low-risk subgroups using either angiographic or clinical variables or both. The composite endpoint of death, MI, or stroke occurred significantly less often in the CABG stratum than in the intensive medical therapy group (24.8 versus 36.8 percent) among those in the highest angiographic risk tertile, and this effect was even more pronounced in patients with both high angiographic and high clinical risk (27.1 versus 47.3 percent; hazard ratio 2.10, p = 0.0051). Although this analysis is limited by small sample size in subgroups and lack of validation of the angiographic risk score used, it suggests that in patients with diabetes, those at highest angiographic and clinical risk benefit the most from revascularization with CABG. In the 381 patients from the CABG stratum that were considered high risk, the rates of death, MI, or stroke at five years were 24.8 percent in the CABG arm and 36.8 percent in the medical therapy arm. In contrast, there were no differences between PCI and medical therapy in the high-risk PCI stratum (29.7 versus 29.9 percent).
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After percutaneous coronary artery intervention — Among diabetic patients who undergo elective PCI, the procedural success rates are similar to patients without diabetes [13-17]. However, patients with diabetes have increased rates of long-term restenosis and progression of coronary disease compared with patients without diabetes, as well as lower rates of event-free survival [13-15,17-27]. The following are examples of this point:
●In an analysis of 10,778 patients in the j-Cypher registry who underwent PCI with sirolimus-eluting stents, there were 966 patients with insulin-treated diabetes, 3404 with diabetes not treated with insulin, and 6378 without diabetes [24]. At three years, the rate of target lesion revascularization was significantly higher in the insulin-treated and noninsulin-treated diabetes groups compared with those without diabetes (19, 14, and 10 percent, respectively). Predictors of restenosis in diabetic patients included smaller vessel caliber, greater length of the stented segment, and lower body mass index, similar to the broad population of patients with CAD.
●The SYNTAX trial, which compared PCI with CABG in patients with complex CAD (left main and/or three vessel disease), included 452 patients with diabetes [28]. At five-year follow-up, the rate of repeat revascularization of patients undergoing PCI (n = 231) was higher in patients with diabetes (29 versus 19 percent). Mortality was also increased in the diabetic population (20 versus 12 percent).
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After coronary artery bypass graft surgery — Among patients who undergo elective CABG, the procedural short-term success rates are similar in patients with and without diabetes. However, during follow-up, death and adverse nonfatal outcomes after CABG are higher in patients with diabetes.
In addition, the risk of sternal wound infection and kidney failure is higher in patients with diabetes [29-31]. It has been suggested that bilateral internal thoracic (mammary) artery grafting may be contraindicated in diabetic patients in whom the incidence of sternal wound infection is as high as 14 percent [31]. Maintenance of strict glycemic control during the perioperative period and skeletonization of the internal mammary artery during harvesting are associated with lower rates of sternal wound infection [32,33]. (See 'Intraoperative and postoperative glycemic control' below and "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Sternal wound infection and mediastinitis' and 'Internal thoracic artery grafts' below.)
Although diabetes does not appear to affect in-hospital mortality after CABG, short- and long-term survival after CABG are significantly reduced in diabetic patients. In different large observational studies, compared with nondiabetic patients, patients with diabetes had higher mortality rates at 30 days (5 versus 2.5 percent) and at 5 and 10 years (22 versus 12 percent and 50 versus 29 percent, respectively) [29,30,34-42]. As with mortality, nonfatal adverse coronary outcomes after CABG also may be somewhat more common in diabetic patients. In a report of over 12,000 patients, diabetes was associated with a significantly lower rate of freedom from PCI at 10 years (83 versus 86 percent) but no difference in either MI or additional CABG at 5 or 10 years [40]. Another report evaluated 1615 patients who underwent CABG at a single center and had one or more repeat angiograms, and they were followed for ≥25 years [41]. Diabetes was associated with a relative risk of 1.39 for progression of atherosclerosis or recurrent symptoms.
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PCI versus CABG — For most patients with diabetes and complex multivessel CAD who require revascularization (see 'Revascularization versus medical therapy for stable angina' above), the evidence suggests outcomes are improved with coronary artery bypass graft surgery (CABG). The evidence comes from the FREEDOM trial and subgroup analysis of the BARI 2D trial of patients with diabetes and subgroup analyses of the SYNTAX trial.
Prior to coronary revascularization, the patient should have the relative benefits and costs of PCI and CABG fully described.
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The EXCEL trial randomized patients with significant left main coronary artery stenosis and low/intermediate SYNTAX score (≤32). All patients had to be candidates for both PCI or CABG. [2] (see "Left main coronary artery disease", section on 'Randomized trials'). In EXCEL, there were 1905 patients (554 patients with diabetes) assessed to have low or intermediate CAD complexity based on a SYNTAX score ≤32. The following findings were noted in EXCEL:
●The three-year composite primary end point (all-cause death, stroke, or MI) was higher in patients with diabetes compared with those without (20.0 versus 12.9 percent; hazard ratio [HR] 1.60, 95% CI 1.26-2.04).
●In patients with diabetes, the rate of the primary end point was similar between those who received PCI or CABG (20.7 versus 19.3 percent, respectively; HR 1.03, 95% CI 0.71-1.50).
●The rate of all-cause death was higher in those treated with PCI (13.6 versus 9.0 percent, respectively; p = 0.046), and there was no significant interaction regarding diabetes status. However, there were only 59 total deaths in the subgroup with diabetes (n = 38 [PCI] versus n = 21 [CABG]), so the study was underpowered to evaluate death as a single endpoint.
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Multivessel or complex disease — In the general population of patients who require coronary revascularization, CABG is preferred to PCI in many patients with multivessel disease. In patients without multivessel coronary artery disease, complex anatomy such as distal left main or proximal left anterior descending coronary artery stenosis, or heavily calcified lesions in tortuous vessels, may influence decision-making in favor of CABG.
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The FREEDOM trial is the largest relevant randomized controlled trial evaluating PCI and CABG in patients with multivessel coronary artery disease. In the FREEDOM trial, 1900 patients with diabetes and multivessel CAD (83 percent three-vessel disease) were randomly assigned to either PCI with early generation drug-eluting stents (DES) or CABG. Both groups received optimal medical therapies for the secondary prevention of cardiovascular disease [43]. The median follow-up among survivors was 3.8 years. The following findings were noted:
●The primary composite outcome of death from any cause, nonfatal MI, or nonfatal stroke occurred significantly more often in the PCI group at five years (26.6 versus 18.7 percent; absolute difference of 7.9 percent, 95% CI 3.3-12.5). The benefit from CABG existed in all SYNTAX score subgroups.
●With regard to the individual components of the composite end point, all-cause mortality and MI were significantly higher with PCI (16.3 versus 10.9 and 13.9 versus 6.0 percent, respectively), whereas stroke occurred significantly less often (2.4 versus 5.2 percent).
●At one year, there was a higher rate of repeat revascularization in the PCI group (12.6 versus 4.8 percent; HR 2.74, 95% CI 1.91-3.89).
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The SYNTAX trial compared first-generation DES with CABG in patients with multivessel coronary artery disease. In this trial, 1800 patients with three-vessel or left main coronary artery disease were randomized to paclitaxel-eluting stent or CABG. A total of 452 patients (25 percent) had diabetes. The following findings were noted:
●In the overall trial cohort at 12 months, major adverse cardiac or cerebrovascular events were higher in the PCI group (17.8 percent [PCI] versus 12.4 percent [CABG]; p = 0.002). The results were consistent in the subgroup with diabetes.
●At three years, in the cohort with diabetes, major adverse cardiac and cerebrovascular event rates were higher with PCI (37 percent [PCI] versus 22.9 percent [CABG]; p = 0.002). The need for repeat revascularization was significantly higher in patients with diabetes treated with PCI (28 percent [PCI] versus 12.9 percent [CABG]; p<0.001) [44].
●At 10 years, there were no significant differences in death between patients treated with PCI compared with CABG (27 percent [n = 244 with PCI] versus 24 percent [n = 211 with CABG]; p = 0.09). In the cohort with diabetes, in whom 10-year outcomes were available in 452, a total of 150 had died. There were no differences in the risk of death at 10 years in patients treated with PCI compared with CABG (HR 1.10; 95% CI 0.80-1.52) [5].
These data should be interpreted with the understanding that the DES used in this trial (paclitaxel-eluting) has been shown to be less effective and inferior to the current generation of DES.
A patient-level meta-analysis that included data from 11 randomized trials evaluating PCI and CABG provides additional evidence for the superiority of CABG for patients with diabetes and multivessel coronary artery disease [4].
●Mortality at five years was significantly higher with PCI in those patients with diabetes and multivessel coronary artery disease compared with CABG (15.5 versus 10.0 percent; HR 1.48; 95% CI 1.019-1.84; p = 0.0004).
●There was no difference in mortality between PCI and CABG in patients with multivessel without diabetes (HR 1.08; 95% CI 0.86-1.36; p = 0.49).
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One- or two-vessel disease — For patients with single-vessel or noncomplex disease for whom revascularization is indicated, PCI is a reasonable choice. While this issue has not been specifically studied, most of our experts prefer PCI to CABG.
Previous coronary artery bypass graft surgery — The optimal revascularization approach in diabetic patients with post-CABG angina is not known. The general approach to the management of post-CABG angina is discussed separately.
PCI is a reasonable first choice for most patients with diabetes and unacceptable angina (with appropriate anatomy) after CABG. Repeat CABG can be considered for patients with multigraft failure or no prior placement of a left internal thoracic artery graft.
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PCI CONSIDERATIONS
Among patients with diabetes who undergo percutaneous coronary intervention (PCI), outcomes such as the rates of target lesion revascularization, MI, or survival may be influenced by the stent type as well as diabetes-related factors.
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Stent type — Similar to the general population of patients who undergo PCI with stent placement, patients who receive current generation drug-eluting stents (DES) have a lower rate of restenosis and subsequent revascularization than those who receive either bare metal stents or early generation DES [45-58]. The newest generation of ultra-thin-strut stents may reduce target lesion failure and MI [59]. However, a patient-level meta-analysis of ultra-thin stents in patients with diabetes did not demonstrate increased benefit [60].
Diabetes-related factors — Several diabetes-related clinical factors have been evaluated for their impact on outcome after PCI:
●The rate of restenosis after PCI in diabetic patients may be lower in the setting of lower glycemia. This was suggested in an analysis from 2004 of 239 patients (179 with diabetes) who underwent elective PCI (67 percent with stenting) after measurement of glycated hemoglobin (HbA1c) [61]. Diabetic patients with a preprocedural HbA1c ≤7 percent had a rate of target vessel revascularization at 12 months that was comparable to that in nondiabetic patients (15 versus 18 percent), while diabetic patients with an HbA1c >7 percent had a significantly higher rate of target vessel revascularization (34 percent). Generalization is limited by the study design (non-randomized observational study), its small size, and potential for confounding.
The potential efficacy of this approach has been evaluated in two small randomized trials in which patients with type 2 diabetes who underwent PCI with stenting were randomly assigned to either a thiazolidinedione (pioglitazone or rosiglitazone) or placebo [62,63]. In both studies, the rate of angiographic restenosis was significantly lower in the thiazolidinedione group. Further studies are required to confirm the efficacy and safety of this approach, particularly with the use of DES since stent technology has evolved since the conduct of these studies.
Lipid-related factors — Lipid-lowering therapy is the cornerstone of secondary prevention measures to reduce future coronary events in patients following PCI.
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CORONARY ARTERY BYPASS GRAFT SURGERY CONSIDERATIONS
Comorbidities — The rates of long-term death and adverse nonfatal outcomes after coronary artery bypass graft surgery (CABG) are higher in patients with diabetes compared with those without diabetes. (See 'Outcomes' above.)
A variety of factors contribute to the worse prognosis. Diabetic patients who undergo CABG have a worse risk profile, tending to be older with more three-vessel disease and lower LVEF than nondiabetic patients [34,36,39,64].
Comorbidities of diabetes influence post-CABG survival. This was illustrated in a cohort of 36,641 patients undergoing isolated CABG between 1992 and 2001: 70 percent did not have diabetes, 22 percent had diabetes without kidney failure (requiring preoperative dialysis) or vascular disease (peripheral or cerebrovascular), and 8 percent had diabetes with kidney failure and/or vascular disease [65]. The annual mortality rate for patients without diabetes (3.1 percent) was similar to that for patients with diabetes but no kidney failure or vascular disease (4.4 percent). Patients with diabetes who had kidney failure and/or vascular disease had a significantly higher annual mortality rate (9.4 percent).
Another observational study of 905 patients found (on multivariate analysis) that an elevated serum creatinine (not kidney failure as in the prior study) was an independent predictor of five-year mortality (adjusted hazard ratio 1.5) [66]. Proteinuria was also an independent predictor of mortality.
Preoperative glycemic control is associated with outcomes following CABG. In 3555 consecutive patients undergoing elective CABG at an academic medical center between 2002 and 2006, increasing HbA1c was associated with increased risk of mortality, MI, and deep sternal wound infection [67]. After adjusting for potential confounders, there was an increased risk of mortality (odds ratio 1.40; 95% CI 1.06-1.86) for every 1 percent increase in HbA1c.
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Internal thoracic artery grafts — All patients undergoing CABG, including those with diabetes, should receive an internal thoracic (mammary) artery (ITA) graft to improve survival.
In addition, we prefer bilateral to single ITA grafting for many patients with diabetes based on two observational studies. This recommendation is made despite the fact that the rate of sternal wound infection may be modestly increased with bilateral compared with single ITA grafting and that diabetes may be a risk factor for the development of postoperative mediastinitis [68,69].
The issue of whether bilateral ITA improves outcomes compared with single ITA in patients with diabetes was evaluated in a study of 1107 consecutive patients who received either a single or bilateral ITA [70]. After propensity matching, two cohorts of 414 individuals were created. There was no significant difference between the single and bilateral ITA groups in operative mortality (2.4 versus 3.1 percent, respectively), sternal wound infection (1.7 versus 3.1 percent), or total complications (17.1 percent). However, late median survival was significantly lower with single ITA grafting (9.8 versus 13.1 years). Similar improvement in long-term survival after placement of bilateral ITA among patients with diabetes was reported in another 2012 observational study [71].
Radial grafts should be considered in patients undergoing CABG, particularly in those patients with diabetes who are relatively young. In a meta-analysis of six trials evaluating the use of radial artery grafts in patients undergoing CABG (mean age 67 and 35 percent with diabetes), the use of radial grafts reduced the rate of death, MI, or revascularization when compared with saphenous vein grafts (hazard ratio [HR] 0.67, 95% CI 0.49-0.90) [72]. Radial arterial grafts were also at lower risk of graft failure (HR 0.44; 95% CI 0.28-0.70). Outcomes were similar in patients with and without diabetes.
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Intraoperative and postoperative glycemic control — For most patients with diabetes, we attempt intensive glycemic control intra- and postoperatively to improve both cardiac and noncardiac outcomes in diabetic patients after CABG [32,73,74]. The following observations illustrate the range of findings:
●In a prospective trial, 141 patients with diabetes who were undergoing CABG were randomly assigned to tight glycemic control (125 to 200 mg/dL [6.9 to 11.1 mmol/L]) with a glucose-insulin-potassium (GIK) infusion or standard therapy with intermittent subcutaneous insulin [74,75]. Patients treated with GIK had lower mean serum glucose concentrations in the perioperative period (138 versus 260 mg/dL [7.7 versus 14.4 mg/dL]). At two years, GIK patients had significantly lower rates of wound infections (1 versus 10 percent), recurrent ischemia (5 versus 19 percent), and mortality (2 versus 10 percent).
●In a randomized trial [76], 352 patients (with or without known diabetes) undergoing CABG were randomized to intensive glucose target (100 to 140 mg/dL) or to a conservative target (141 to 180 mg/dL). In the cohort with diabetes, there were no differences in the rates of complications in patients treated in the intensive or conservative group (49 versus 48 percent, p = 0.87).
RECOMMENDATIONS OF OTHERS
Our recommendations are similar to those from the American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society for Cardiovascular Angiography and Interventions/Society of Thoracic Surgeons in 2014 and those from the European Society of Cardiology/European Association for the Study of Diabetes in 2013
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SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
Society guideline links: Percutaneous coronary intervention
Introduction
This topic includes links to society and government-sponsored guidelines from selected countries and regions around the world. We will update these links periodically; newer versions of some guidelines may be available on each society's website. Some societies may require users to log in to access their guidelines.
The recommendations in the following guidelines may vary from those that appear in UpToDate topic reviews. Readers who are looking for UpToDate topic reviews should use the UpToDate search box to find the relevant content.
Links to related guidelines are provided separately.
Canada
●Thrombosis Canada: Duration of dual antiplatelet therapy in patients with coronary artery disease (2024)
United States
●ACC/AHA/SCAI: Guideline for coronary artery revascularization, 2021 (published 2022)
Europe
●European Society of Cardiology (ESC): Guidelines for the management of chronic coronary syndromes (2024)
●ESC: Guidelines for the management of acute coronary syndromes (2023)
United Kingdom
●NICE: HealthTech guidance on bioresorbable stent implantation to treat coronary artery disease (2022)
●NICE: Guideline on acute coronary syndromes (2020)
●NICE: Quality standard on acute coronary syndromes in adults (2014, updated 2020)
●NICE: Clinical guideline on stable angina – Management (2011, updated 2016)
●SIGN: A national clinical guideline on acute coronary syndrome (2016)
Australia–New Zealand
Japan
●[In English] Japanese Circulation Society: Guideline focused update on diagnosis and treatment in patients with stable coronary artery disease (2022)
●[In Japanese] JCS: Guideline focused update on diagnosis and treatment in patients with stable coronary artery disease (2022)
●[In English] JCS: Guideline focused update on antithrombotic therapy in patients with coronary artery disease (2020)
●[In Japanese] JCS: Guidelines focused update on antithrombotic therapy in patients with coronary artery disease (2020)
●[In English] JCS/Japanese Society for Cardiovascular Surgery (JSCVS): Guideline on revascularization of stable coronary artery disease, 2018 (published 2022)
●[In English] JCS: Guideline on diagnosis of chronic coronary heart diseases, 2018 (published 2021)
●[In Japanese] JCS: Guideline on diagnosis of chronic coronary heart diseases, 2018 (published 2019)
●[In English] JCS: Guideline on diagnosis and treatment of acute coronary syndrome, 2018 (published 2019)
●[In Japanese] JCS: Guideline on diagnosis and treatment of acute coronary syndrome, 2018 (published 2019)
●[In Japanese] JCS: Guideline on revascularization of stable coronary artery disease (2018)
Society guideline links: Coronary artery bypass graft surgery
Introduction
This topic includes links to society and government-sponsored guidelines from selected countries and regions around the world. We will update these links periodically; newer versions of some guidelines may be available on each society's website. Some societies may require users to log in to access their guidelines.
The recommendations in the following guidelines may vary from those that appear in UpToDate topic reviews. Readers who are looking for UpToDate topic reviews should use the UpToDate search box to find the relevant content.
Links to related guidelines are provided separately.
International
Canada
United States
●ACC/AHA/Society for Cardiovascular Angiography and Interventions (SCAI): Guideline for coronary artery revascularization, 2021 (published 2022)
Europe
●European Society of Cardiology (ESC): Guidelines for the management of chronic coronary syndromes (2024)
●ESC: Guidelines for the management of acute coronary syndromes (2023)
United Kingdom
●National Institute for Health and Care Excellence (NICE): HealthTech guidance on MiraQ for assessing graft flow during coronary artery bypass graft surgery (2011, updated 2022)
●NICE: Guideline on acute coronary syndromes (2020)
●NICE: Clinical guideline on stable angina – Management (2011, updated 2016)
●SIGN: A national clinical guideline for the management of chronic heart failure (2016)
●SIGN: A national clinical guideline on acute coronary syndrome (2016)
●NICE: HealthTech guidance on endoscopic saphenous vein harvest for coronary artery bypass grafting (2014)
●NICE: HealthTech guidance on off-pump coronary artery bypass grafting (2011)
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