Outcomes after primary coronary intervention with drug-eluting stent implantation in diabetic patients with acute ST elevation myocardial infarction.

Abstract

Drug-eluting stent (DES) has been used widely for the treatment of patients with acute coronary syndrome with or without diabetes mellitus during percutaneous coronary intervention (PCI), but its long-term safety and efficacy in diabetic patients with acute ST elevation myocardial infarction (STEMI) remain uncertain. This study aimed to investigate the clinical outcomes after primary coronary intervention with DES implantation for diabetic patients with acute STEMI, compared with non-diabetic counterparts.
From December 2004 to March 2006, 56 consecutive diabetic patients (diabetic group) and 170 non-diabetic patients (non-diabetic group) with acute STEMI who underwent primary PCI with DES implantation in 3 hospitals were enrolled. Baseline clinical, angiographic, and procedural characteristics, as well as occurrence of major adverse cardiac event (MACE) including cardiac death, non-fatal recurrent myocardial infarction (re-MI) and target vessel revascularization (TVR) during hospitalization and one-year clinical follow-up were compared between the two groups.
Patients in diabetic group were more hyperlipidemic (69.6% and 51.8%, P = 0.03) and had longer time delay from symptom onset to admission ((364 +/- 219) minutes and (309 +/- 223) minutes, P = 0.02) than those in non-diabetic group. The culprit vessel distribution, reference vessel diameter, and baseline TIMI flow grade were similar between the two groups, but multi-vessel disease was more common in diabetic than in non-diabetic group (82.1% and 51.2%, P < 0.001). Despite similar TIMI flow grades between the two groups after stenting, the occurrence of TIMI myocardial perfusion grade (TMPG) = 2 was lower in diabetic group (75.0% vs 88.8% in non-diabetic groups, P = 0.02). The MACE rate was similar during hospitalization between the two groups (5.4% vs 3.5%, P = 0.72), but it was significantly higher in diabetic group (16.1%) during one-year follow-up, as compared with non-diabetic group (6.5%, P = 0.03). The cumulative one-year MACE-free survival rate was significantly lower in diabetic than in non-diabetic group (78.6% vs 90.0%, P = 0.02). Angiographic stent thrombosis occurred in 5.4% and 1.2% of the patients in diabetic and non-diabetic group, respectively (P = 0.19). All of these patients experienced non-fatal myocardial infarction.
Although the early clinical outcomes were similar in diabetic and non-diabetic patients with acute STEMI treated with DES implantation, the cumulative MACE-free survival at one-year follow-up was worse in diabetic than in non-diabetic patients. More effective diabetes-related managements may further improve the clinical outcomes of diabetic cohort suffering STEMI.

Full text

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Chin Med J 2007;120(21):1862-1867
1862
Original article

Outcomes after primary coronary intervention with drug-
eluting stent implantation in diabetic patients with
acute ST elevation myocardial infarction

ZHANG Qi, SHEN Jie, ZHANG Rui-yan, QIU Jian-ping, LU Ji-de, ZHANG Yu, CHEN Yue-hua, ZHANG Jun-feng,
ZHANG Jian-sheng, HU Jian, YANG Zhen-kun, ZHENG Ai-fang, ZHANG Xian and SHEN Wei-feng

Keywords: acute myocardial infarction; drug-eluting stent; clinical outcome; primary coronary intervention

Background Drug-eluting stent (DES) has been used widely for the treatment of patients with acute coronary
syndrome with or without diabetes mellitus during percutaneous coronary intervention (PCI), but its long-term safety and
efficacy in diabetic patients with acute ST elevation myocardial infarction (STEMI) remain uncertain. This study aimed to
investigate the clinical outcomes after primary coronary intervention with DES implantation for diabetic patients with acute
STEMI, compared with non-diabetic counterparts.
Methods From December 2004 to March 2006, 56 consecutive diabetic patients (diabetic group) and 170 non-diabetic
patients (non-diabetic group) with acute STEMI who underwent primary PCI with DES implantation in 3 hospitals were
enrolled. Baseline clinical, angiographic, and procedural characteristics, as well as occurrence of major adverse cardiac
event (MACE) including cardiac death, non-fatal recurrent myocardial infarction (re-MI) and target vessel
revascularization (TVR) during hospitalization and one-year clinical follow-up were compared between the two groups.
Results Patients in diabetic group were more hyperlipidemic (69.6% and 51.8%, P=0.03) and had longer time delay
from symptom onset to admission ((364±219) minutes and (309±223) minutes, P=0.02) than those in non-diabetic group.
The culprit vessel distribution, reference vessel diameter, and baseline TIMI flow grade were similar between the two
groups, but multi-vessel disease was more common in diabetic than in non-diabetic group (82.1% and 51.2%, P<0.001).
Despite similar TIMI flow grades between the two groups after stenting, the occurrence of TIMI myocardial perfusion
grade (TMPG) ≥2 was lower in diabetic group (75.0% vs 88.8% in non-diabetic groups, P=0.02). The MACE rate was
similar during hospitalization between the two groups (5.4% vs 3.5%, P=0.72), but it was significantly higher in diabetic
group (16.1%) during one-year follow-up, as compared with non-diabetic group (6.5%, P=0.03). The cumulative one-year
MACE-free survival rate was significantly lower in diabetic than in non-diabetic group (78.6% vs 90.0%, P=0.02).
Angiographic stent thrombosis occurred in 5.4% and 1.2% of the patients in diabetic and non-diabetic group, respectively
(P=0.19). All of these patients experienced non-fatal myocardial infarction.
Conclusions Although the early clinical outcomes were similar in diabetic and non-diabetic patients with acute STEMI
treated with DES implantation, the cumulative MACE-free survival at one-year follow-up was worse in diabetic than in
non-diabetic patients. More effective diabetes-related managements may further improve the clinical outcomes of
diabetic cohort suffering STEMI.
Chin Med J 2007;120(21):1862-1867

P
rimary percutaneous coronary intervention (PCI) with
bare-metal or drug-eluting stent (DES) implantation
for patients with acute ST elevation myocardial infarction
(STEMI) has now been utilized as the standard of care,
because of considerable survival benefit.1-3 Patients with
diabetes mellitus who presented with acute STEMI often
have a higher risk of adverse outcomes than non-diabetic
counterparts,4 due probably to extensive coronary disease
or poor left ventricular function. Although DES is thought
to be more favorable than bare-metal stent with respect to
reduction of restenosis and target vessel revascularization
(TVR), neointimal hyperplasia may persist after
sirolimus-eluting stent implantation in diabetes,5 and
long-term beneficial effects of DES for the treatment of
diabetic patients with acute STEMI remain uncertain.
This study aimed to compare in-hospital and one-year
follow-up outcomes after primary PCI with DES
implantation for diabetic patients with acute STEMI, with
those in non-diabetic controls.
METHODS

Study population
This prospective study included 226 consecutive patients
with acute STEMI presented within 12 hours of symptom
onset and treated with primary PCI from December 2004
to March 2006 in 3 hospitals in Shanghai. Fifty-six
Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong
University School of Medicine, Shanghai 200025, China (Zhang
Q, Shen J, Zhang RY, Zhang JS, Hu J, Yang ZK, Zheng AF, Zhang
X and Shen WF)
Department of Cardiology, Shanghai Gongli Hospital, Shanghai
200025, China (Qiu JP, Lu JD and Zhang Y)
Department of Cardiology, Third People’s Hospital, Shanghai Jiao
Tong University School of Medicine, Shanghai 200025, China
(Chen YH and Zhang JF)
Correspondence: Dr. SHEN Wei-feng, Department of Cardiology,
Ruijin Hospital, Shanghai Jiao Tong University School of Medicine,
Shanghai 200025, China (Email: rjshenweifeng@yahoo.com.cn)
This study was supported by the grant from Shanghai Science and
Technology Foundation (No. 05DZ19503).

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Chinese Medical Journal 2007; 120(21):1862-1867
1863
(24.8%) patients with diabetes mellitus (DM) were
included into the diabetic group, and the remaining 170
(75.2%) patients were served as control (non-diabetic
group). DM was considered if patients received active
treatment with an oral hypoglycemic agent or insulin.6
Patients with history of abnormal glucose-tolerance test
were excluded. The diagnosis of STEMI was based on
severe chest pain which persisted for longer than 30
minutes and was not relieved by sublingual nitrate,
typical ST-segment elevation on standard 12-lead
electrocardiogram (i.e., at least 2 mm of ST-segment
elevation in 2 or more contiguous chest leads and at least
1 mm in 2 or more contiguous limb leads), and/or
elevation of serum cardiac enzymes (e.g., creatine
kinase-MB) or biomarkers (troponin T or I). Exclusion
criteria included administration of fibrinolytic agents for
the index infarction, overt heart failure or cardiogenic
shock, presence of contraindication to aspirin and/or
clopidogrel.

Medication and PCI procedure
Patients were given a loading dose of anti-platelet agents
(aspirin 300 mg and clopidogrel 300 mg) in the
emergency room once the diagnosis of acute STEMI was
made. Intravenous platelet glycoprotein (GP) IIb/IIIa
receptor inhibitor (tirofiban) was used at operator’s
discretion.

Coronary angiography was performed through right
femoral approach. The infarct-related artery was filmed in
at least two orthogonal projections after intracoronary
administration of 200 µg of nitroglycerin. A bolus of
unfractionated heparin (7500 U) was given followed by
additional dose, if necessary, to maintain adequate
activated clotting time (>250 seconds) during the
procedure. Sirolimus or paclitaxel DES was implanted
according to standard technique described previously,7
and direct stenting was allowed if suitable culprit lesion
was visualized either spontaneously or after guidewire
placement. Online quantitative coronary analysis was
performed with the software (TERRA, GE), and
epicardial blood flow in the infarct-related artery before
and after stent implantation was determined according to
the Thrombolysis in Myocardial Infarction (TIMI)
classification.8 TIMI myocardial perfusion grade (TMPG)
was evaluated densitometrically on the basis of a visual
assessment of relative contrast opacification of the
myocardial territory subtended by the infarct vessel in
relation to epicardial density.9 Procedural success was
defined as residual stenosis ≤20% with TIMI flow≥2, and
without in-hospital major adverse events (including death,
recurrent myocardial infarction (re-MI), emergency
coronary artery bypass grafting (CABG)). After
procedures, aspirin (100 mg/d) was continued in all
patients indefinitely, and clopidogrel (75 mg/d) was given
for at least one year.

Study end points and follow-up
The primary end point of the study was major adverse
cardiac events (MACE), defined as the composite of
cardiac death, non-fatal re-MI and TVR during
hospitalization and at one-year clinical follow-up.
Cardiac death included death from acute MI, cardiac
perforation, or pericardial tamponade, or arrhythmias and
all deaths that could not be clearly attributed to a
noncardiac cause. Re-MI was defined as the recurrence of
clinical symptoms with ECG changes or/and a new
elevation in serum creatine kinase MB. TVR was defined
as repeated PCI or bypass grafting of the target vessel.
The secondary end point included TIMI flow and TMPG
immediately after the procedure. Stent thrombosis was
evaluated and classified as definite, probable and possible
stent thrombosis according to the Academic Research
Consortium (ARC) definition.10 Clinical follow-up after
discharge was performed by out-patient clinic interview
or telephone contact in all patients or their relatives.

Statistical analysis
Data are presented as proportion or mean (±standard
deviation (SD)). Differences between groups were
compared using Student’s unpaired t test or Wilcoxon
rank-sum test for continuous variables and with Fisher’s
exact test for categorical variables. The primary end point
at one year was estimated by the Kaplan-Meier method.
SPSS software (Version 10.0, SPSS Chicago) was used
for statistical analysis. A two-sided P value of less than
0.05 was considered statistically significant.

RESULTS

Clinical and procedural characteristics
Baseline clinical characteristics of both groups were well
matched, besides more patients in diabetic group had
hyperlipidemia (69.6% and 51.8%, P=0.03). The median
time from the onset of chest pain to hospital admission
was longer ((364±219) minutes and (309±223) minutes,
P=0.02), and patients with Killip Class ≥3 at presentation
was non-significantly increased in the diabetic group
(Table 1). The use of GP IIb/IIIa receptor inhibitors did
not differ significantly between the two groups (Table 2),
and all patients received loading doses of aspirin and
clopidogrel before the procedure.

Lesion distribution, reference vessel diameter, and TIMI
flow grade before PCI were similar between the two
groups, but patients in diabetic group had more
multi-vessel disease than non-diabetic groups (82.1% and
51.2%, P<0.001). The use of sirolimus-eluting stent
(89.3% in diabetic group and 85.9% in non-diabetic
group) was more often than paclitaxel-eluting stent
(10.7% in diabetic group and 14.1% in non-diabetic
group). Mean stent diameter and length, and final balloon
inflation pressure were similar in the two groups.
Although the final TIMI flow grade did not differ
between the two groups, the number of patients with
TMPG ≥2 after stent implantation was significantly
smaller in the diabetic group compared with non-diabetic
group (75.0% and 88.8%, P=0.02). Diabetic patients
received more elective PCI for non-culprit coronary
arteries, but the rate of complete revascularization was

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Chin Med J 2007;120(21):1862-1867
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Table 1. Baseline clinical characteristics
Diabetic group (n=56)
68.7±8.4
44 (78.6)
45 (80.4)
39 (69.6)
31 (55.4)
31 (55.4)
5 (8.9)
13 (23.2)
3 (5.4)
364±219
84.6±18.0
113.9±43.2
67.7±29.0
Variables
Age (year)
Male ((n)%)
Hypertension ((n)%)
Hyperlipidemia ((n)%)
Hypercholesterolemia ((n)%)
Current smoker ((n)%)
Family history of CAD ((n)%)
Previous MI ((n)%)
Previous PCI ((n)%)
Time from symptom onset to admission (min)
Heart rate (beats/min)
Systolic pressure (mmHg)
Diastolic pressure (mmHg)
MI location
Anterior ((n)%)
Inferior ((n)%)
Others ((n)%)
Killip class ≥3 ((n)%)
Non-diabetic group (n=170)
63.4±12.8
143 (84.1)
138 (81.2)
88 (51.8)
79 (46.5)
112 (65.9)
11 (6.5)
24 (14.1)
9 (5.3)
309±223
81.3±20.9
129.3±37.1
70.8±33.2
P value
0.55
0.45
0.95
0.03
0.32
0.21
0.75
0.17
0.75
0.02
0.55
0.32
0.49
37 (66.1)
14 (25.0)
5 (8.9)
8 (14.3)
94 (55.3)
59 (34.7)
17 (10.0)
14 (8.2)
0.21
0.24
0.98
0.29

Table 2. Angiographic and procedural features
Diabetic group (n=56) Variables
Coronary artery disease ((n)%)
1 vessel
2 vessels
3 vessels
Infract-related artery ((n)%)
left anterior descending artery
left circumflex artery
right coronary artery
Others
Pre-stent TIMI flow ((n)%)
0
1
2
3
Reference diameter (mm)
Lumen diameter stenosis (%)
Stent diameter (mm)
Stent length (mm)
No. of stents implanted per patient
Maximal balloon inflation pressure (atm)
Direct stent implantation ((n)%)
Sirolimus-eluting stent ((n)%)
Paclitaxel-eluting stent ((n)%)
Post-stent TIMI flow ((n)%)
0
1
2
3
Post-stent TMPG
0
1
2
3
Final lumen diameter (mm)
Final diameter stenosis (%)
Use of platelet GP IIb/IIIa inhibitor ((n)%)
Elective PCI for non-culprit artery ((n)%)
Complete revascularization before discharge ((n)%)
Hospital stay (day)
Non-diabetic group (n=170) P value
10 (17.9)
26 (46.4)
20 (35.7)
83 (48.8)
57 (33.6)
30 (17.6)
<0.001
0.12
0.008
36 (64.2)
5 (8.9)
9 (16.1)
1 (1.8)
91 (53.5)
19 (11.2)
40 (23.5)
3 (1.8)
0.21
0.82
0.32
0.57
43 (76.8)
7 (12.5)
4 (7.1)
2 (3.6)
3.01±0.37
0.99±0.04
3.04±0.41
28.36±6.17
1.0±0.0
12.64±1.55
4 (7.1)
50 (89.3)
6 (10.7)
125 (73.5)
17 (10.0)
16 (9.4)
12 (7.1)
3.15±0.33
0.96±0.13
3.20±0.47
24.40±6.26
1.01±0.13
13.70±1.79
19 (11.2)
146 (85.9)
24 (14.1)
0.76
0.78
0.81
0.54
0.21
0.26
0.16
0.13
0.32
0.55
0.54
0.67
0.67
0 (0)
4 (7.1)
16 (28.6)
36 (64.3)
0 (0)
11 (6.5)
33 (19.4)
126 (74.1)
1.00
0.89
0.21
0.21
3 (5.4)
11 (19.6)
21 (37.5)
21 (37.5)
3.01±0.22
7.8±4.7
51 (91.1)
40 (71.4)
39 (69.6)
12.6±5.4
3 (1.8)
16 (9.4)
35 (20.6)
116 (68.2)
3.11±0.35
9.3±6.1
149 (87.6)
73 (42.9)
149 (87.6)
10.3±4.7
0.33
0.07
0.02
<0.001
0.74
0.69
0.65
<0.001
0.004
0.15

still lower than non-diabetic patients before discharge
(Table 2).

Follow-up
All MACEs during hospitalization and one-year
follow-up are listed in Table 3. Two patients in each
group died of cardiogenic shock, and 3 patients in
non-diabetic group died due to ventricular arrhythmias
during hospitalization. The overall MACE rate was
similar in diabetic and non-diabetic group (5.4% and
3.5%, P=0.72). The primary end point of MACE at
one-year clinical follow-up was 16.1% and 6.5% in

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1865
diabetic and non-diabetic group, respectively (P=0.03).
Kaplan-Meier survival analysis and log-rank test revealed
that one-year cumulative MACE-free survival also
significantly differed between the two groups (78.6% and
90.0%, P=0.02) (Fig).


Fig. Cumulative MACE-free survival rate between the two
groups at one-year follow-up.

During follow-up, stent thrombosis was documented by
coronary angiography in 3 diabetic (5.4%) and 2
non-diabetic patients (1.2%). One patient in each group
died of suspected stent thrombosis during follow-up
(Table 3).

Table 3. Clinical outcomes during hospitalization and at
one-year clinical follow-up
Outcomes
Diabetic
group (n=56)
Non-diabetic
Group (n=170)
P
value
In-hospital ((n)%)
Cardiac death
Re-myocardial infarction
Target vessel revascularization
Major adverse cardiac events
One-year follow-up ((n)%)
Cardiac death
Re-myocardial infarction
Target vessel revascularization
Major adverse cardiac events
Definite stent thrombosis
Probable/possible stent thrombosis

2 (3.6)
1 (1.8)
1 (1.8)
3 (5.4)
5 (2.9)
1 (0.6)
1 (0.6)
6 (3.5)
0.84
0.67
0.99
0.72
1 (1.8)
3 (5.4)
8 (14.3)
9 (16.1)
3 (5.4)
1 (1.8)
2 (1.2)
5 (2.9)
9 (5.3)
11(6.5)
2 (1.2)
1 (0.6)
0.78
0.44
0.06
0.03
0.19
0.99
DISCUSSION

We investigated the clinical outcomes of diabetic patients
with acute STEMI treated with primary PCI and DES
implantation. The results showed that diabetic patients
had more severe coronary disease and impaired
myocardial perfusion after primary PCI, and reduced
one-year cumulative MACE-free survival rate, when
compared with non-diabetic counterparts. The occurrence
rate of stent thrombosis was considerably low. These
results imply that DES may be safe in the interventional
treatment for patients with diabetes and acute STEMI, but
more effective anti-diabetic therapy is still required for
diabetic patients to further improve the clinical outcomes.
Although advances in treatment for patients suffering
acute STEMI have significantly reduced mortality rate
over the last decade, patients with diabetes are still at
high risk of restenosis and death even after receiving
mechanical reperfusion.11 The introduction of DES
significantly improves the clinical outcomes in patients
with coronary artery disease by reducing the restenosis
and subsequent TVR,12,13 even in the diabetic
population.14 Results from several recent studies showed
that DES significantly reduced need for revascularization
in patients with acute myocardial infarction and was not
associated with an increased risk of stent thrombosis at
one-year follow-up.3,15,16 In the Sirolimus-Eluting Stent
versus bare-metal stent in Acute Myocardial Infarction
(SESAMI) randomized clinical trial, the implantation of
sirolimus-eluting stent reduced incidence of binary
restenosis by 56%, TVR by 62% and adverse cardiac
events by 59% at one-year, as compared with bare metal
stent.2 Previously diagnosed diabetes has been reported to
occur in 20% to 25% of patients presented with STEMI,17
and there is no study focusing on the prognosis of these
patients treated with primary PCI and DES implantation.

The result of our study showed that diabetic patients with
acute STEMI was more often accompanied with
hyperlipidemia than those non-diabetic, consistent with
previous findings.18 An increased incidence of silent
myocardial ischemia and infarction in diabetic patients
may contribute to late presentation for medical attention
and subsequent delayed initiation of treatment.19 In this
study, time from symptom onset to admission for diabetic
group was still significantly longer than that for
non-diabetic patients, despite emphasis of continuous
education on the importance of early presentation and the
potential atypical clinical manifestations of myocardial
ischemia in diabetic patients in recent years. The presence
of diabetes has been proved to increase the risk of
developing coronary artery disease.20 In the current study,
more patients in diabetic group had multivessel disease
(82.1% and 51.2%, P<0.001), although the location of
culprit vessel and reference vessel diameter were similar
to those in non-diabetics.

The introduction of stent and platelet GP IIb/IIIa
inhibitors in conjunction with primary PCI reduces the
risk of recurrent ischemia and improves clinical outcomes
after primary PCI.21,22 In our study, most of the patients
(91.1% in diabetic and 87.6% in non-diabetic group) were
treated by platelet GP IIb/IIIa inhibitors, the result
showed that although TIMI flow grade was similar
between the two groups immediately after DES
implantation, the percentage of patients with TMPG≥2
was still significantly lower in the diabetic group (75.0%),
as compared with non-diabetics (88.8%, P=0.02). At
one-year clinical follow-up, the incidence of TVR (14.3%
and 5.3%, P=0.06) and primary end point of MACE rate
were significantly higher in diabetic than in non-diabetic
group. Kaplan-Meier survival analysis revealed that
cumulative MACE-free survival rate at one-year
follow-up was significantly lower in the diabetic group.

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Chin Med J 2007;120(21):1862-1867
1866
Stent thrombosis has been regarded as a serious
complication in contemporary DES era.23 The reported
incidence of stent thrombosis after DES implantation
varies from 0.6% to 1.27%.24,25 Diabetes and treatment in
a setting of myocardial infarction were identified as
independent predictor of stent thrombosis, besides
premature antiplatelet discontinuation, renal failure,
bifurcation lesions and lower ejection fraction.26 In the
current study, angiographically
thrombosis occurred in 3 (5.4%) and 2 (1.2%) patients in
diabetic and non-diabetic group, respectively. Comparing
to the results previously reported, the incidence of stent
thrombosis in the diabetic group in our study was higher,
which may be caused by the complex clinical setting of
the patients included. DM was reported to be associated
with poor platelet responsiveness to in vitro effect of
aspirin in a recent study,27 which suggested that higher
doses of anti-platelet therapy might be needed in these
patients. In our study, all the patients with stent
thrombosis experienced non-fatal recurrent myocardial
infarction during follow-up. The long-term results of the
DIABETES trial was reported by Jimenez-Quevedo et
al,28 which showed that
implantation in diabetic patients with de novo coronary
stenosis remains effective at 2-year follow-up. However,
clinical efficacy appeared to be reduced by the increased
occurrence of stent thrombosis between 1 and 2 years
after index procedure in the diabetic group.28 In the
current study, we prolonged the dual anti-platelet therapy
with aspirin and clopidogrel in the diabetic group
indefinitely, considering the high prevalence of stent
thrombosis in this subset.

In the present study, we did not specify type 1 or 2
diabetes due to the limited number of patients in diabetic
group. Therefore, this study did not clarify the difference
in clinical outcomes between type 1 and 2 diabetic
patients with acute STEMI treated with primary DES
implantation. Although MACE rate during hospitalization
was similar in the two groups, we need to consider the
insufficient statistical power to show a difference in those
events. Limited patients in the diabetic group may also
contribute to the elevated incidence of stent thrombosis
reported in the current study. Further studies with large
number of patients from multi-centers are needed to
obtain more convincing evidence.

In summary, despite similar in-hospital clinical outcomes,
diabetic patients presented with acute STEMI and treated
with primary PCI plus DES implantation still had worse
prognosis at one-year follow-up. The cumulative
MACE-free survival rate was significantly lower in
diabetic than in non-diabetic patients. Given the rapidly
increasing number of patients with diabetes and complex
coronary lesions, more effective therapeutic strategies,
including aggressive lipid-lowering and diabetes-related
managements, should be pursued to further improve the
long-term clinical outcomes for diabetic patients with
acute STEMI.
determined stent
sirolimus-eluting stent
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