Speaker: Efrain Goxola, MD, Cardiology and Internal Medicine, Instituto Cardiovascular Guadalajara, Guadalajara, Mexico

A further analysis of the data from the INVest (The International Verapamil SR-Trandopril Study) trial suggested that a regimen of sustained-release verapamil (Isoptin®, Abbott Laboratories) provided an alternative to atenolol (AstraZeneca) for preventing adverse cardiovascular outcomes, including coronary revascularization in hypertensive patients with coronary artery disease (CAD).

The INVEST trial included 22,576 patients who were randomly assigned to receive either a verapamil SR-based or an atenolol-based regimen. Flexible dose titration and the addition of trandolapril (Mavik®, Abbott) for the verapamil SR patients and/or hydrochlorothiazide (Diovan®, Novartis) for the patients were used to achieve target treatment goals in accordance with JNC VI (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) of below 140/90 mm Hg or below 130/85 mm Hg for patients with diabetes or renal impairment. The average follow-up period was 2.7 years. The risk for “primary outcome” (first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke) was equivalent for the two regimens.

The objective of the INVEST substudy was to analyze the impact of treatment strategies, baseline risk factors, blood pressure (BP) control and average on-treatment BP on coronary revascularizations during the trial, because patients with hypertension and CAD often require coronary artery bypass grafting or percutaneous coronary intervention. The incidence of follow-up coronary revascularization was similar between the two groups (with verapamil, 2.5%; with atenolol canadian, 2.4%), and it remained similar whether or not the patients had undergone a prior revacularization.

The increased risk of revascularization during follow-up was associated with U.S. residency, previous revascularization, hyper-cholesterolemia, male sex, unstable angina, and diabetes. In addition, patients with a low mean follow-up diastolic BP (below 70 mm Hg) or a high diastolic BP (above 90 mm Hg) were at an increased risk of needing revascularization at follow-up.

Pioglitazone Reduces In-Stent Restenosis in Diabetes

Speaker: Jin Yokayama, MD, Instructor in Interventional Cardiology, Cardiology Division, Department of Medicine, Hirosaki University School of Medicine, Hirosaki, Japan

Although drug-eluting stents have dramatically decreased the incidence of in-stent restenosis (ISR) in patients with diabetes mellitus, ISR remains a clinically important problem. Insulin sensitizers have an anti-atherosclerotic effect and seem to reduce neointimal tissue proliferation after coronary stent-ing in these patients.

A study was conducted to determine whether low-dose pioglitazone (Takeda) would reduce the incidence of ISR after coronary angioplasty in 40 patients with type-2 diabetes mellitus who had bare metal stents. Pioglitazone 15 mg/day was orally administered for six months to 16 patients with 24 lesions that had been stented; previous antidiabetic therapy was maintained. The incidence of ISR in these patients was compared with the other 24 patients (with 26 lesions stented) who had received conventional antidiabetic therapy that did not include pioglitazone canadian.

The success rate associated with bare metal stent placement was 100% in both pioglitazone patients and controls. At six months after the procedures, however, the angiographic rate of ISR, defined as stenosis of greater than 50% in diameter, was significantly lower in the pioglitazone patients (8.3%) than in the control patients (42.3%). ISR was documented after angiography in only two of the 24 lesions stented in the treated group.

In patients with controlled glycemic levels (glycosylated hemoglobin below 6.5% at follow-up), ISR and target lesion revascularization rates, as noted with angiography, were significantly lower.