Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada; Instituto do Coracao (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil.
Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada.
Can J Cardiol. 2019 Aug;35(8):993-1001. doi: 10.1016/j.cjca.2019.03.010. Epub 2019 Mar 20.
The prevalence of diabetes mellitus (DM) is rising globally and in Canada. Besides being a risk factor for the development of coronary artery disease, DM is also a marker of poor prognosis in patients with acute coronary syndrome (ACS), increasing the risks for ischemic and bleeding complications. Patients with DM have a high prevalence of multivessel coronary artery disease (MVD) and robust evidence has supported coronary artery bypass surgery (CABG) as the optimal revascularization strategy in the setting of stable ischemic heart disease. In the acute scenario, particularly in patients with non-ST-segment elevation (NSTE) ACS (NSTE-ACS), there are many uncertainties regarding the best revascularization strategy. Most guidelines suggest an invasive and timely approach (that is, performing coronary catheterization within 72 hours after the onset of the NSTE-ACS) and make recommendations about choosing between percutaneous coronary intervention (PCI) or CABG on the basis of data for patients with stable ischemic heart disease. Recent observational and subgroup analyses suggest that CABG might be the preferential method of revascularization for patients with DM and MVD also in the NSTE-ACS setting; however, dedicated randomized clinical trials are lacking. Finally, in patients who present with an ST-segment elevation myocardial infarction, the initial revascularization method of choice is generally PCI, instead of fibrinolysis or CABG, and DM status most often does not influence this decision. The management of residual MVD after primary PCI for ST-segment elevation myocardial infarction, however, remains controversial.
糖尿病（DM）的患病率在全球和加拿大都呈上升趋势。除了是冠状动脉疾病发展的危险因素外，DM 也是急性冠状动脉综合征（ACS）患者预后不良的标志物，增加了缺血和出血并发症的风险。DM 患者多支冠状动脉疾病（MVD）的患病率较高，有强有力的证据支持冠状动脉旁路移植术（CABG）作为稳定型缺血性心脏病患者的最佳血运重建策略。在急性情况下，特别是在非 ST 段抬高型 ACS（NSTE-ACS）患者中，关于最佳血运重建策略存在许多不确定性。大多数指南建议采用侵入性和及时的方法（即在 NSTE-ACS 发作后 72 小时内进行冠状动脉造影），并根据稳定型缺血性心脏病患者的数据，就 PCI 或 CABG 之间的选择提出建议。最近的观察性和亚组分析表明，在 NSTE-ACS 患者中，CABG 可能是 MVD 合并 DM 患者的首选血运重建方法；然而，缺乏专门的随机临床试验。最后，对于出现 ST 段抬高型心肌梗死的患者，首选的初始血运重建方法通常是 PCI，而不是溶栓或 CABG，并且 DM 状态通常不会影响这一决策。然而，ST 段抬高型心肌梗死患者行直接 PCI 后残余 MVD 的处理仍存在争议。
