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Original article

Influence of insulin resistance on long-term outcomes in patients with coronary artery disease after sirolimus-eluting stent implantation

ZHAO, Liang-ping; LÜ, An-kang; SHEN, Wei-feng; LIU, Hai-feng; MA, Xiao-ye; FAN, Xiao-ming; ZHANG, Qi

Editor(s): WANG, Mou-yue

Author Information
doi: 10.3760/cma.j.issn.0366-6999.2010.06.003
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Insulin resistance (IR) is typically defined as decreased sensitivity and responsiveness to metabolic actions of insulin that promote glucose disposal. The important feature of diabetes, obesity, glucose intolerance, and dyslipidemia, is also a prominent component of cardiovascular disorders including coronary artery disease (CAD), atherosclerosis and hypertension.1-4 Several studies have shown that IR is a significant risk factor for CAD and cardiovascular events in patients with or without type 2 diabetes mellitus (T2DM).5,6 Compared with non-diabetic counterparts, patients with T2DM often have IR and require more cardiovascular care. Unfortunately, patients with T2DM continue to have significant complications after percutaneous coronary intervention (PCI), including restenosis, myocardial infarction and early or late mortality.7

Homeostasis model assessment (HOMA) index is used to assess IR in many patients, in whom fasting serum insulin and glucose levels are simply measured.8,9 It is not only a perfect parameter for investigating the role of IR and insulin secretion in the development of diabetes, but also a good expression for evaluating the jeopardy of IR in Chinese with cardiovascular diseases.10 Considering that IR is a risk factor for CAD and correlated with the outcome of CAD patients, we examined the prognostic value of IR in patients undergoing sirolimus-eluting stent (SES)-based PCI using the HOMA index.


Patient selection

We studied 467 consecutive patients undergoing PCI with SES implantation from July 2007 to May 2008 in the Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. The patients who met the following criteria were excluded: (1) acute coronary syndrome and primary angioplasty; (2) history of PCI or coronary artery bypass graft; (3) NYHA class III or IV before PCI despite optimal pharmacological therapy; (4) inflammation-related diseases; (5) severe liver and kidney dysfunction; and (6) malignant tumor.

The protocol of this study was approved by the Hospital Ethics Committee, and written informed consent was obtained from all patients.

Coronary intervention

Pre-medications with aspirin 100 mg and clopidogrel 75 mg daily were commenced at least 2-3 days before the procedure. Loading doses of aspirin (300 mg) and clopidogrel (450-600 mg) were always given to those who were not pre-medicated. Coronary angiography and PCI procedures were performed using standard techniques through femoral or radial approaches.11 Angiographic analysis was carried out by 2 experienced interventional cardiologists, who were not informed the study protocol. The number of diseased coronary arteries (luminal diameter narrowing ≥70%) was recorded, and patients with stenosis of the left main coronary artery ≥50% were considered to have two-vessel disease.12 All patients enrolled in this study underwent a successful angioplasty and a SES implantation, and complete revascularization was achieved if there was no remnant vessel stenosis ≥30%.

After the procedure, the patients were maintained with clopidogrel 75 mg daily for at least 1 year, and aspirin 100 mg daily infinitely. Other medications such as statins, angiotensin-converting enzyme inhibitors, beta-blockers and calcium antagonists were administered when indicated.

Biochemical investigations

Blood samples were collected after overnight fasting, and stored at -70°C prior to analysis. Serum glucose level was measured by the glucose oxidase method and insulin concentration was assessed using radioimmunoassay techniques. The insulin resistance index (IRI) was expressed by homeostasis model assessment for insulin resistance (HOMA-IR) calculated from (fasting serum glucose (mmol/L)×fasting plasma insulin (mU/L))/22.5.8 IRI ≥2.69 was defined as IR and IRI <2.69 was insulin sensitivity based on a scale Chinese population study.12 Serum high-sensitivity C-reactive protein (hsCRP) level was determined using a high-sensitivity ELISA kit (Biocheck Laboratories, USA). Serum lipid profiles including triglyceride, total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and lipoprotein(a), and blood urea nitrogen and creatinine were assessed using standard methods.13


The 467 patients were followed up in a special outpatient clinic or by telephone conversation every 3 months after discharge. Cardiac events including cardiac death, non-fatal myocardial infarction and recurrent angina pectoris were recorded. Myocardial infarction was defined as presence of typical chest pain, electrocardiographic ST-segment elevation with or without Q waves, and serum cardiac enzyme elevations at least twice the upper limit of normal range. Cardiac death was considered if death occurred suddenly or was associated with documented myocardial infarction, congestive heart failure and malignant ventricular arrhythmias. Recurrent angina pectoris was defined by the Canadian Cardiovascular Society (CCS) class ≥II grade. In order to guarantee rigorous data quality, all cardiac events were reviewed by two experienced interventional cardiologists.

Statistical analysis

All statistical analyses were performed using SPSS 13.0 for Windows (SPSS Inc, Chicago, IL, USA). Baseline characteristics were compared using the chi-square test for categorical variables (presented as counts and percentages) and independent-sample t test for continuous variables (mean ± standard deviation (SD)). Abnormally distributed data were analyzed using the Mann-Whitney U test. The unadjusted cumulative incidence of cardiac events was determined by the Kaplan-Meier method and the log-rank test. After testing all variables, those associated with event rates on univariate analysis at P ≤0.2 entered a multivariate Cox proportional hazards regression model with a backward stepping algorithm to analyze the independent risk factors for cardiac events during follow-up. All tests of significance were two-tailed and a P value <0.05 was considered statistically significant.


Baseline characteristics

Of the 467 patients, 104 had an IRI ≥2.69 (the IR group), and 363 had an IRI <2.69 (the non-IR group). T2DM, hypertension, and multi-vessel disease were more common in the IR group, and the levels of serum glucose at fasting and 2 hours after glucose load, insulin, hemoglobin A1c (HbA1c), triglycerides, lipoprotein-a as well as body mass index and stent length were higher, but the level of HDL-C was lower (Table 1). And IR was significantly associated with hypertension, diabetes, dyslipidemia, obesity, and multi-vessel disease by univariate analysis (Table 2).

Table 1
Table 1:
Baseline characteristics and biochemical assessments
Table 2
Table 2:
Relationship between IR and other variables

In 122 patients with T2DM, 44 (36.1%) had IR. The levels of fasting glucose ((8.07±3.14) vs. (6.80±2.28) mmol/L), insulin ((18.16±15.72) vs. (6.56±2.30) mU/L), and triglycerides ((2.17±1.85) vs. (1.69±0.79) mmol/L) were higher and left ventricular ejection fraction ((60.24±9.96)% vs. (63.93±5.61)%) was lower in patients with T2DM and IR than in those with non-RI (all P <0.05); but body mass index, stent length, HbA1c, incidence of hypertension and multi-vessel disease were not significantly different.

Of 345 non-diabetic patients, 60 (17.4%) experienced IR. The levels of fasting glucose ((5.83±1.18) vs. (5.10±0.89) mmol/L), glucose 2 hours after load ((9.22±3.50) vs. (7.55±2.56) mmol/L), fasting insulin ((17.37±7.07) vs. (6.01±2.57) mU/L), triglycerides ((2.49±2.40) vs. (1.77±1.02) mmol/L), as well as body mass index ((26.68±3.31) vs. (24.33±2.80) kg/m2) were higher and multi-vessel disease (63.3% vs. 50.8%) was more common in non-diabetic patients with or without RI (all P <0.05).

Cardiac events

During the follow-up ((9.03±3.07) months for the IR group; (9.14±2.61) months for the non-IR group), 6 patients (1.28%) had cardiac death, 2 (0.43%) suffered from non-fatal myocardial infarction, and 22 (4.71%) had recurrent angina pectoris. There was a significant difference in cardiac events between the two groups (Figure 1A).

Figure 1.
Figure 1.:
Comparison of cardiac events between the two groups in total patients (A), T2DM subgroup (B), and non-diabetic group (C).

In the T2DM subgroup, 4 patients (3.28%) had cardiac death and 10 (8.20%) experienced recurrent angina pectoris, but none had non-fatal myocardial infarction. There were a non significantly higher rate of cardiac death and a significantly higher incidence of recurrent angina pectoris in the RI group than in the non-RI group (Figure 1B). In the non-diabetic patients, 2 had cardiac death (0.58%), 2 (0.58%) suffered from non-fatal myocardial infarction, and 12 (3.48%) had recurrent angina pectoris. No significant differences were found between the two groups (Figure 1C).

Survival results

The Kaplan-Meier analysis with the log-rank test revealed that patients in the IR group had higher cumulative rates of MACE (P=0.002), cardiac death (P=0.009) and recurrent angina pectoris (P=0.049) than those in the non-IR group during the follow-up (Figure 2). In the T2DM subgroup, the presence of IR was not associated with a significant increase in cardiac death (log-rank test, P=0.098), but correlated with an increased incidence of recurrent angina pectoris (log-rank test, P=0.030) (Figure 3A and 3B). In addition, IR was significantly associated with reduced MACE-free survival (log-rank test, P=0.027), but not with recurrent angina pectoris (log-rank test, P=0.919) in the non-diabetic patients (Figure 3C and 3D).

Figure 2.
Figure 2.:
MACE-free Kaplan-Meier survival curve for all patients.
Figure 3.
Figure 3.:
MACE-free Kaplan-Meier survival curve for patients with T2DM (A and B), and non-diabetic group (C and D).

Cox regression analysis

Cox proportional hazard regression analysis was made to adjust baseline covariates, including age, gender, T2DM, hypertension, smoking history, presentation of acute coronary syndrome, dyslipidemia, obesity, left ventricular ejection fraction and multi-vessel disease. IR was an independent risk factor for the incidence of MACE in all patients (OR=2.76, 95% CI=1.35-5.47, P=0.034). The significant predictors for recurrent angina pectoris included age (OR =3.25, 95% CI=1.15-9.72, P=0.047), T2DM (OR =3.74, 95% CI=1.23-8.46, P=0.020), and multi-vessel disease (OR=5.33, 95% CI=1.09-11.19, P=0.025).

In the T2DM subgroup, hypertension (OR=2.87, 95% CI=1.54-7.84, P=0.043) and hypercholesterolemia (OR=2.91, 95% CI=1.24-8.98, P=0.033) but not IR (OR=1.69, 95% CI=0.74-3.51, P=0.137) were independent predictors for MACE occurrence during the follow-up. IR (OR =3.35, 95% CI =1.07-13.59, P =0.013) and multi-vessel disease (OR =2.19, 95% CI =1.01-5.14, P=0.044) were significantly associated with recurrent angina pectoris. And IR was not shown to be an independent risk factor for the occurrence of MACE in the non-diabetic patients.

Thus IR was an independent risk factor for the occurrence of MACE in the non-diabetic patients.


This study demonstrated that the presence of IR was associated with a striking increase in mortality, non-fatal myocardial infarction and recurrent angina pectoris during the follow-up. Despite the association of IR with multiple high-risk features known to affect the prognosis of patients after drug-eluting stent-based PCI, at least moderate IR was one of the strongest independent predictors for diminished survival.

IR is a key component of metabolic syndrome, and plays an important role in various cardiovascular disorders.14,15 Numerous studies have demonstrated detrimental impacts of IR on the development of coronary atherosclerosis, plaque instability, and cardiovascular events in patients with or without T2DM.16 Hyperinsulinemia, an indirect indicator for insulin sensitivity, is closely associated with mortality due to cardiovascular diseases.5,17 A recent study on insulin resistance atherosclerosis showed that IR rather than insulin concentration is an independent and powerful risk factor for CAD.18 The mechanism by which IR provokes cardiovascular disease is mainly related to the development of metabolic syndrome. Patients with IR exhibit high concentrations of serum triglyceride, lipoprotein, and apolipoprotein B, as well as a low concentration of HDL-cholesterol,19,20 indicating that dyslipidemia is associated with the development of cardiovascular disease. In addition, IR has been shown to reduce flow-mediated vasodilation of the brachial artery, cause endothelial dysfunction, trigger inflammatory signaling, and increase the formation of advanced glycation end products.21-24 As reported previously,25,26 IR was found to be correlated with triglyceride level and was inversely related to HDL-cholesterol in the present study.

Drug-eluting stents have now been applied to almost all types of coronary lesions in patients with various clinical presentations, leading to improved outcomes in those patients at high-risk.27,28 To date, however, few large-scale studies have been conducted to examine the relationship between IR and long-term clinical outcomes in patients undergoing SES-based PCI. Lazzeri et al29 have observed that IR, as assessed by HOMA index, was quite common and helpful in the early prognostic stratification, and represented an independent predictor of in-hospital mortality in non-diabetic patients with ST-elevation myocardial infarction undergoing primary PCI. Yun et al30 analyzed 98 consecutive non-diabetic patients who underwent elective coronary angioplasty, and revealed that IRI ≥2.6 was an independent predictor of in-hospital and 30-day MACE rates. However, these studies were limited by small sample size, chaos of angioplasty methods, and short period of follow-up. In the present study, we enrolled more patients, and excluded those with acute coronary syndrome, primary PCI, and severe cardiac dysfunction. This would make the assessment of prognostic value of IR for patients undergoing PCI more exactly. The results indicated that IR may significantly influence the MACE-free survival rate of patients undergoing SES-based PCI and is an independent risk factor for cardiac death and non-fatal myocardial infarction during the follow-up.

Recurrent angina pectoris after PCI is one of the important factors that influence the life quality of patients with CAD. The mechanisms may include in-stent restenosis, stent thrombosis, side branch involvement, coronary spasm, multi-vessel disease, and plaque progression.31-33 In patients with IR, coronary spasm may be induced by an imbalance between endothelin-1 and NO secretion, and thrombosis and plaque instability are easily triggered by activating inflammatory signaling, increased platelet function, and anticoagulation/fibrolysis dysfunction.22,34-36 In addition, multi-vessel disease and long lesions which are more common in patients with IR could cause frequent distal occlusion. Nishimura et al37 reported that IR might be involved in the progression of non-culprit coronary atherosclerosis and contribute to the poor prognosis after PCI with bare metal stent implantation in hemodialysis patients. Our study showed that patients with T2DM more frequently experienced recurrent angina pectoris after PCI with SES implantation, especially for those with IR and multi-vessel disease.

As previously reported that hypertension and hypercholesterolemia are significantly associated with MACEs in patients undergoing PCI,38-40 the two factors are also independent predictors for the incidence of MACE during the follow-up in patients with T2DM. It has been shown that hypertension and dyslipidemia are closely associated with IR.41,42

In conclusion, IR is significantly associated with poor long-term outcomes in patients after PCI with SES implantation. Appropriate therapies for ameliorating IR may be crucial to reduce subsequent cardiac events in these patients.


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insulin resistance; coronary artery disease; sirolimus-eluting stent; long-term prognosis

© 2010 Chinese Medical Association