Diabetic: Bypass apparently better than stent

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Coronary artery disease is often the result of diabetes

Most diabetics experience consequential damage over the years due to the chronically elevated blood sugar level. There are often diseases of the coronary arteries - which is why the question is discussed and investigated in new research projects, what is more useful for the treatment of diabetes patients: bypass surgery or the insertion of a so-called "stent", a medical implant, which is inserted into the narrowed vessels to keep them open.

New international study shows: a bypass is the most sensible treatment
This question now seems to be answered by a current international study, because the results of the long-term study published in the "New England Journal of Medicine" at the beginning of November 2012 clearly show: Patients who suffer from coronary arteries that are constricted multiple times should undergo bypass surgery rather than undergo surgery to have a stent placed. According to the study, the number of deaths and heart attacks in diabetic patients who had received a bypass was less within five years than in those who had received vascular support.

Study participants: 1900 diabetics worldwide
Between 2005 and 2010, a total of 1900 diabetics from 140 clinics worldwide participated in the study, including treatment centers from the USA, Canada, Brazil, India, France and Spain. The examined patients, 71% men and 29% women, were on average 63 years old and all suffered from multiple constricted coronary arteries, in 83% of the test persons the vessels were narrowed at three passages. Two groups were formed: one was bypassed to bridge the congested coronary arteries, the other group was inserted into the narrowed vessels by means of a catheter coated with stents in order to expand them and to release small amounts of medication prevent a new closure.

With bypass: Significantly fewer deaths and heart attacks, slightly more strokes
After the interventions, there was an observation period of five years, after which the doctors had a clear result: While in the group of bypass patients 10.9 percent of those affected had died within the five years, the proportion of those who died was in the group 16.3 percent of those who received a stent. The number of heart attacks was also significantly higher in the stent group: 13.6 of the patients were affected, whereas the proportion in the bypass group was only 6 percent.

However, the number of strokes was exactly the opposite: only 2.4% of patients with an implanted stent had a stroke within five years, while the proportion of bypass patients was 5.2%.

Vascular changes occur earlier in diabetics
According to Professor Friedrich-Christian Rieß, Chairman of the Albertinen Heart and Vascular Center Hamburg and Chief Physician of Cardiac Surgery, the positive results within the Bypass Group had several reasons: First, the diameter of the coronary artery in diabetics is often smaller than in people without diabetes. On the other hand, especially in diabetes patients, vascular changes in the sense of arteriosclerosis, also known as “hardening of the arteries” or “hardening of the arteries”, would occur significantly earlier than in non-diabetics. Because, according to the professor, the vessels would change much more quickly in diabetics, and these changes were more diffuse: “This means that not only does the arterial outlet narrow, but they often extend through the entire vessel to the tip . But that also means that it is often a long-term narrowing. And the longer the distance that often has to be supplied with stents, the greater the risk that it will narrow again, "said the doctor.

Study result also clear for cardiac specialists at the UKE Also for the cardiac specialists of the Clinic for General and Interventional Cardiology at the University Heart Center of the Eppendorf University Clinic, the result of the study is clear: "It confirms our previous approach. Bypass surgery is also used at the UKE for diabetics with diseases the treatment of several coronary arteries is the first choice of therapy ", says the director of the clinic Prof. Stefan Blankenberg.

Stroke rate could be reduced by gentle surgical techniques
According to Professor Rieß, the somewhat increased number of strokes after a bypass operation could also be reduced further - using gentler surgical techniques. Because in this country - like in the USA - the heart-lung machine is still operated frequently and partial veins are used for the bypasses, which would be implanted in the main artery. However, according to the professor, these procedures would involve risks, since calcifications could be released from the wall of the main artery, which could reach the brain via the bloodstream and trigger a stroke there.

Alternative method of bypass: using the sternum arteries
For this reason, according to Professor Rieß, in the Albertinen Heart and Vascular Center Hamburg a method is used in most cases in which the main artery is not touched at all. Instead, another route would be chosen: "We operate the patient on the beating heart without using the heart-lung machine and use the sternum arteries for the bypass, which are connected to the coronary arteries." According to Riess, this procedure can almost rule out a stroke - because in the sternum arteries, deposits due to arteriosclerosis would never occur for previously unexplained reasons, which in turn means that there is only a minimal risk of a new vascular occlusion. According to the professor, this would be different if venous vessels were used, because "if these become part of the arterial system, they begin to arm themselves against the unusually high blood pressure by converting their vascular wall. However, this increases the risk that it will be there comes to new restrictions ". According to Riess, a study here would have shown that just under two thirds of the venous bypasses were still open after ten years.

German Diabetes Society calls for more information From the point of view of the German Diabetes Society (DDG), there is now an urgent need for action in view of the study results: "Counseling and treatment of people with heart disease with diabetes must improve," says Professor Dr. med. Stephan Matthaei, President of the DDG. It is imperative that doctors inform their patients about the survival benefit of bypass surgery before a catheter examination, because this is the only way for diabetic heart patients to make an informed decision.

This is also the opinion of Professor Dr. Andreas Fritsche, press spokesman for the German Diabetes Society in Tübingen: "Heart-diabetic patients should know this before a planned catheter examination so that they can make an informed decision for bypass or stent". This is the only way to ensure that the patient has enough time "to discuss his therapy decision with his family, the cardiac team treating him and his diabetologist thoroughly." Because of the study results, the doctor must assume that many diabetic heart patients are currently suffering would not be treated properly. (sb)

Also read:
New stents improve heart attack forecast
Blood type affects risk of heart attack
Stress at work leads to a heart attack
Heart attack worse in the morning than in the evening
The number of children with diabetes is increasing rapidly
New hope for heart attack patients

Picture: Dieter Schütz, Pixelio

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