[Heart-diabetes-network--a concept for improved care for diabetic cardiovascular patients following cardiac surgical intervention]. / Herz-Diabetes-Netz--Konzept zur verbesserten Versorgung herzkranker Diabetiker nach kardiochirurgischer Intervention.

Diabetic patients with heart disease are high risk patients for further vascular complications and therefore need an intensive and multimodal, interdisciplinary intervention. Due to the "segmentation" of medical care into primary care physician, specialists, acute and secondary care (rehabilitation) clinics, the patients will be taken care of on each individual segment with regard to the current requirements and specialties of the care provider. Such--each section, the GP, the cardiologist and the diabetologist, the heart centre and the rehabilitation clinic, represent individual and often strictly separate segments, which each will focus only on the acute problem and will collect (only) data required for the care in their particular segment. A multimodal approach can improve the chronic care and prognosis of these patients, as shown in several studies. The proposed network model should increase multi-disciplinary cooperation of the different levels of health care segments and overcome current barriers. It is thus necessary to provide common guidelines for diagnostic and therapeutic procedures and to improve communication between each individual sector. This could help to improve the secondary prevention in these high risk patients.

[Experiences collected in more than 2,300 diabetics undergoing coronary artery bypass grafting: patients with a specific risk profile]. / Erfahrungen mit Diabetikern in der Koronarchirurgie--Patienten mit einem besonderen Risikoprofil.

BACKGROUND: The objective of this paper was to analyze demographic and clinical characteristics of diabetic patients undergoing coronary artery bypass grafting on the basis of a significant number of cases. METHODS: The data of 8,195 patients who have undergone coronary bypass operations between 1996 and 2003 were analyzed. Non-diabetic patients (no DM), oral treated diabetics (DM oral) and insulin-treated diabetics (DM insulin) were compared in terms of their pre-operative, intra-operative and post-operative characteristics. The statistical analyses were performed with the support of SPSS 11.5 under application of chi-square and student-t tests. RESULTS: In cardiosurgery, diabetics differ in various ways from non-diabetic patients. They show a significantly higher prevalence of the known cardiovascular risk factors such as raised body mass index, age and hypertension. Furthermore they present a higher prevalence of vascular comorbidity such as peripheral vascular disease and carotid disease. At the postoperative stage, cerebral dysfunction occurred more often among the diabetic patients (no DM 5.2% vs. DM oral 7.3% vs. DM insulin 10.5%; p < 0.05), they suffered from apoplexies more frequently (no DM 1.9% vs. DM oral 2.1% vs. DM insulin 3.2%; p < 0.05), and they required re-intubation more frequently (no DM 2.6% vs. DM oral 3.1% vs. DM insulin 5.6%; p < 0.05). Peri-operative mortality was highest in the group of insulin-treated diabetics (no DM 1.1% vs. DM oral 1.6% vs. DM insulin 1.8%; p < 0.05). CONCLUSION: In coronary surgery, diabetic patients represent an especially challenging patient group with an independent risk profile, who require specific consideration as far as the selection of the operative approach, on, one hand, and the post-operative follow-up, on the other hand, are concerned.

Diabetes mellitus in coronary artery surgery: therapeutic strategies in the light of recent studies.

Advances in percutaneous coronary revascularization have meant that, increasingly, patients with multivessel diseases are initially treated with the methods of interventional cardiology. Ongoing studies involving new stent coatings and optimized anti-thrombotic therapies could help to lower future restenosis rates and improve the success rate of stenting. Thrombocyte glycoprotein IIb/IIIa receptor blockers have already been shown to reduce the rate of acute PTCA complications in high-risk patients and could have a sustained impact on the long-term prognoses for PTCA patients. However, for diabetic patients with coronary multivessel diseases, coronary artery bypass grafting using arterial grafts as the initial revascularization method must be given preference over other therapy methods. Consequently, this group of patients is bound to grow in importance in cardiac surgery. The advances made in percutaneous coronary revascularization and in coronary surgery call for further prospective, controlled, randomized clinical studies in order to establish the best possible treatment strategy for patients with diabetes. It should be noted, however, that the therapeutic effect of myocardial revascularization is generally limited to individual coronary-arterial segments, whereas the pathological process of atherosclerosis is rather diffuse. The surgical strategy should therefore be seen as part of an overall strategy which encompasses other forms of treatment (e.g. intensive efforts to improve control of blood glucose level, blood pressure, and cholesterol level) in order to arrest the general progression of the disease and to reduce the risk of myocardial infarction and death.