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Patients with coronary artery disease and diabetes exhibit more extensive atherosclerosis compared to patients without diabetes, according to findings.

"Patients with diabetes have a markedly increased incidence of adverse cardiovascular events and less favorable outcomes from myocardial infarction or after coronary interventions," write Dr. Stephen J. Nicholls and colleagues from the Cleveland Clinic, Ohio. The underlying mechanisms, however, have not been well characterized.

The team performed a systematic analysis of data on 2237 patients with coronary artery disease who underwent serial evaluation by intravascular ultrasound in various randomized controlled studies of atherosclerosis progression.

Results of multivariate analysis controlling for differences in risk factors demonstrated that patients with diabetes had a greater per cent atheroma volume (PAV) (p < 0.0001) and total atheroma volume (TAV) (p = 0.03).

Glycated hemoglobin was more closely related to PAV and TAV than was fasting glucose, Dr. Nicholls and colleagues report, although the difference failed to meet statistical significance after controlling for study.

Diabetic subjects had smaller lumen volume than non-diabetic subjects (291.1 mm³ versus 306.5 mm³, p = 0.005). However, there was no difference between the groups in external elastic membrane volume (494.9 mm³ versus 498.8 mm³, p = 0.61).

Patients with diabetes exhibited more rapid progression of PAV (p = 0.0001) and TAV (p = 0.03) on multivariate analysis.

Diabetic patients treated with insulin had smaller external elastic membrane and lumen volumes. This resulted in a larger PAV in these subjects, despite the presence of a similar TAV.

The investigators note that intensive low-density lipoprotein cholesterol lowering in patients improved the rate of plaque progression - but only to the level seen in nondiabetic subjects with suboptimal lipid control.

The findings "support the need to develop new antiatherosclerotic strategies in diabetic patients," Dr. Nicholls and colleagues conclude.

J Am Coll Cardiol 2008;52:255-262