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Physical examination, resting ECG, and routine laboratory testing should be performed within 7 days after PCI. Special attention should be given to puncture site healing, haemodynamics, and possible anaemia or CIN. For ACS patients, plasma lipids should be re-evaluated 4–6 weeks after an acute event and/or initiation of lipid-lowering therapy to evaluate whether target levels have been achieved and to screen for liver dysfunction; the second plasma lipid control should be scheduled at 3 months [ 263 ]. For patients with stable CAD, there is a need to evaluate muscle symptoms and enzymes initially after statin introduction, then to evaluate muscle symptoms at each follow-up visit, and to evaluate enzymes if the patient presents muscle soreness, tenderness, or pain. Liver enzymes should be evaluated initially, 8–12 weeks after statin initiation, after dose increase, then annually or more frequently if indicated.

Previously published guidelines [ 269 ] and several authors warn against routine testing of asymptomatic patients. Others argue that all patients should undergo stress testing following revascularization, given the adverse outcome associated with silent ischaemia. Early stress testing in order to verify that culprit lesions have been successfully treated may be recommended after incomplete or suboptimal revascularization as well as in other specific patient subsets ( Table 40 ). Stress ECG should preferably be combined with functional imaging, due to low sensitivity and specificity of stress ECG alone in this subset [ 269 ], its inability to localize ischaemia, and to assess improvement in regional wall motion of revascularized segments. Exercise is considered the most appropriate stressor, but in patients unable to exercise, pharmacologic stressors – dipyridamole, dobutamine, and adenosine – are recommended. The inability to perform an exercise stress test, by itself, indicates a worse prognosis. The choice between imaging modalities is based on similar criteria to those used before intervention (Section 5). With repeated testing, radiation burden should be considered as part of the test selection. Estimation of coronary flow using transthoracic Doppler echocardiography may be used to assess coronary flow non-invasively, but larger studies are needed to confirm the accuracy of this technique.

Table 40
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Strategies for follow-up and management in asymptomatic patients after myocardial revascularization

Table 40
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Strategies for follow-up and management in asymptomatic patients after myocardial revascularization

CT angiography can detect occluded and stenosed grafts with very high diagnostic accuracy [ 18 , 19 ]. However, clinical assessment should not be restricted to graft patency but should include evaluation of the native coronary arteries. This will often be difficult because of advanced CAD and pronounced coronary calcification. Furthermore, it is acknowledged that anatomical imaging by CT angiography does not assess ischaemia, which remains essential for therapeutic decisions. CT angiography can detect in-stent restenosis, depending on stent type and diameter, yet the aforementioned limitations equally apply. Patients who have undergone unprotected LM PCI may be scheduled for routine control CT or invasive angiography within 3–12 months.

SENIOR was a phase 3b, randomized, open-label, 2-arm, parallel-group, multicenter, 30-week trial. Randomization was stratified by screening HbA 1c (<8.0 vs ≥8.0 %), previous insulin use (Yes/No), and sulfonylurea or meglitinide use at screening (Yes/No). Insulin was titrated to the ADA-recommended glycemic target for healthy elderly individuals (fasting SMPG: 90–130 mg/dL [5.0–7.2 mmol/L]), a higher glycemic target than utilized previously in randomized controlled trials of insulin glargine 300 U/mL (Gla-300) versus 100 U/mL (Gla-100) in adults. The aim of the SENIOR trial was to compare the efficacy and safety of Gla-300 with Gla-100.

In total, 1014 individuals (≥65 years) with T2DM were included in the trial, of whom 241 were ≥75 years old. The primary endpoint of non-inferiority of mean change in HbA 1c for Gla-300 versus Gla-100 was achieved (least squares mean difference [95% CI]: 0.02, [−0.092 to 0.129] %). Similar percentages of participants in both groups reported confirmed (≤70 mg/dL [≤3.9 mmol/L]) or severe hypoglycemia. The annualized rates of documented symptomatic (≤70 mg/dL [≤3.9 mmol/L]) hypoglycemia were lower with Gla-300 versus Gla-100, both in the overall study population (1.85 vs 2.56 events/participant-year; rate ratio [RR] 0.74 [0.56 to 0.96]) and in the ≥75 years subpopulation (1.12 vs 2.71 events/participant-year; RR 0.45 [0.25 to 0.83]). Frequency of adverse events, including cardiovascular events, falls and fractures was similar between treatments.

These results indicate that Gla-300 was effective in older people with T2DM, with a good safety profile, resulting in comparable reductions in HbA 1c and lower rates of documented symptomatic hypoglycemia versus Gla-100.

Supported By: Sanofi ( NCT02320721)

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© The Author 2017. Published by Oxford University Press on behalf of The Gerontological Society of America.
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