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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetes is a highly complex and heterogeneous disease&#46; Chronic hyperglycemia and progressive insulin resistance lead to various levels of endothelial dysfunction&#44; oxidative stress&#44; thrombus formation&#44; impaired fibrinolysis and a chronic inflammatory state that raises levels of circulatory cytokines such as intercellular adhesion molecule-1 &#40;ICAM-1&#41;&#44; vascular adhesion molecule-1 &#40;VCAM-1&#41; and interleukin-6&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> The presence of diabetes thus leads to increasing vascular calcification and promotes the transformation of stable plaques into unstable ones&#44; with a consequent increase in acute coronary syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Diabetes raises the risk of coronary artery disease &#40;CAD&#41; 2&#8211;4 fold&#44; and it is common knowledge that approximately 80&#37; of diabetic patients die from cardiovascular disease&#44; mostly ischemic events&#44; as they are prone to accelerated atherosclerosis and atherothrombosis&#44; which begins at an early stage of the condition&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Diabetic patients more often present with diffuse and extensive CAD&#44; heavily calcified arteries&#44; reduced vessel diameter and multivessel involvement&#46; Additionally&#44; their clinical presentation may mean that their clinical assessment and diagnosis are more challenging&#44; as these patients tend to present with non-typical symptoms or even silent myocardial ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Chronic total occlusions &#40;CTOs&#41;&#44; which are present in approximately 40&#37; of patients with diabetes&#44; are usually highly complex lesions with lower procedural success rates and with higher risk of procedural adverse events&#46; The evidence supporting percutaneous coronary intervention &#40;PCI&#41; in this subset of patients is controversial&#46; One study analyzed 2015 patients and reported a lower rate of major adverse cardiovascular events &#40;MACE&#41; in diabetic patients successfully treated with CTO-PCI versus medical treatment&#44; but the same benefit was not observed in the non-diabetic group&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In another study&#44; prospectively assessing the five-year cardiovascular survival of successful CTO-PCI in patients with or without diabetes&#44; non-diabetic patients had better long-term survival&#44; with fewer MACE than those without diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> A recent meta-analysis that included two randomized controlled trials and 14 observational studies concluded that&#44; after CTO-PCI&#44; non-diabetic patients had lower all-cause mortality and MACE than patients with diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this context&#44; Costa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> conducted an interesting retrospective study in 177 patients undergoing CTO-PCI in which they analyzed symptom recurrence &#40;primary outcome&#41; and myocardial infarction&#47;all-cause mortality &#40;secondary outcomes&#41; in a two-year follow-up in diabetic and non-diabetic patients&#46; After revascularization&#44; the overall group&#44; which had mildly depressed left ventricular ejection fraction &#40;LVEF&#41; at baseline&#44; improved to preserved LVEF at follow-up&#46; The primary outcome occurred in a small number of patients and was similar between groups&#44; although angina recurrence was significantly more frequent in diabetic patients&#44; who consequently were found to have more significant atherosclerotic disease progression than non-diabetics but&#44; curiously&#44; similar rates of stent restenosis&#46; No differences were found regarding the composite secondary endpoint&#44; regardless of the lower creatinine clearance in diabetic patients and the fact that it was identified as an independent predictor of all-cause mortality&#46; In conclusion&#44; after successful CTO recanalization&#44; the presence of diabetes was not associated with significant long-term clinical repercussions&#44; and further studies are needed to confirm the benefits of CTO-PCI in this group&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Percutaneous coronary intervention in chronic total occlusions: Should it be avoided in type 2 diabetic patients?
Intervenção coronária percutânea em oclusões crónicas totais: deverá ser evitada nos doentes com diabetes tipo 2?
Joana Delgado-Silvaa,b
a Cardiovascular Intervention Unit, Cardiology Department, Coimbra Hospital and University Center, Coimbra, Portugal
b Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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        "titulo" => "Interven&#231;&#227;o coron&#225;ria percut&#226;nea em oclus&#245;es cr&#243;nicas totais&#58; dever&#225; ser evitada nos doentes com diabetes tipo 2&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetes is a highly complex and heterogeneous disease&#46; Chronic hyperglycemia and progressive insulin resistance lead to various levels of endothelial dysfunction&#44; oxidative stress&#44; thrombus formation&#44; impaired fibrinolysis and a chronic inflammatory state that raises levels of circulatory cytokines such as intercellular adhesion molecule-1 &#40;ICAM-1&#41;&#44; vascular adhesion molecule-1 &#40;VCAM-1&#41; and interleukin-6&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> The presence of diabetes thus leads to increasing vascular calcification and promotes the transformation of stable plaques into unstable ones&#44; with a consequent increase in acute coronary syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Diabetes raises the risk of coronary artery disease &#40;CAD&#41; 2&#8211;4 fold&#44; and it is common knowledge that approximately 80&#37; of diabetic patients die from cardiovascular disease&#44; mostly ischemic events&#44; as they are prone to accelerated atherosclerosis and atherothrombosis&#44; which begins at an early stage of the condition&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Diabetic patients more often present with diffuse and extensive CAD&#44; heavily calcified arteries&#44; reduced vessel diameter and multivessel involvement&#46; Additionally&#44; their clinical presentation may mean that their clinical assessment and diagnosis are more challenging&#44; as these patients tend to present with non-typical symptoms or even silent myocardial ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Chronic total occlusions &#40;CTOs&#41;&#44; which are present in approximately 40&#37; of patients with diabetes&#44; are usually highly complex lesions with lower procedural success rates and with higher risk of procedural adverse events&#46; The evidence supporting percutaneous coronary intervention &#40;PCI&#41; in this subset of patients is controversial&#46; One study analyzed 2015 patients and reported a lower rate of major adverse cardiovascular events &#40;MACE&#41; in diabetic patients successfully treated with CTO-PCI versus medical treatment&#44; but the same benefit was not observed in the non-diabetic group&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In another study&#44; prospectively assessing the five-year cardiovascular survival of successful CTO-PCI in patients with or without diabetes&#44; non-diabetic patients had better long-term survival&#44; with fewer MACE than those without diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> A recent meta-analysis that included two randomized controlled trials and 14 observational studies concluded that&#44; after CTO-PCI&#44; non-diabetic patients had lower all-cause mortality and MACE than patients with diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this context&#44; Costa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> conducted an interesting retrospective study in 177 patients undergoing CTO-PCI in which they analyzed symptom recurrence &#40;primary outcome&#41; and myocardial infarction&#47;all-cause mortality &#40;secondary outcomes&#41; in a two-year follow-up in diabetic and non-diabetic patients&#46; After revascularization&#44; the overall group&#44; which had mildly depressed left ventricular ejection fraction &#40;LVEF&#41; at baseline&#44; improved to preserved LVEF at follow-up&#46; The primary outcome occurred in a small number of patients and was similar between groups&#44; although angina recurrence was significantly more frequent in diabetic patients&#44; who consequently were found to have more significant atherosclerotic disease progression than non-diabetics but&#44; curiously&#44; similar rates of stent restenosis&#46; No differences were found regarding the composite secondary endpoint&#44; regardless of the lower creatinine clearance in diabetic patients and the fact that it was identified as an independent predictor of all-cause mortality&#46; In conclusion&#44; after successful CTO recanalization&#44; the presence of diabetes was not associated with significant long-term clinical repercussions&#44; and further studies are needed to confirm the benefits of CTO-PCI in this group&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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