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J Am Coll Cardiol. 2016 Sep 6;68(10):985-95. doi: 10.1016/j.jacc.2016.06.021.

Medical Treatment and Revascularization Options in Patients With Type 2 Diabetes and Coronary Disease.

Author information

1
Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address: mancini@mail.ubc.ca.
2
Department of Medicine, Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre of Excellence, University of Toronto, Toronto, Ontario, Canada.
3
Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania.
4
St. Louis University School of Medicine, St. Louis, Missouri.
5
Department of Medicine, Albany Medical College, Albany, New York.
6
West Haven Veterans Administration Coordinating Center, West Haven, Connecticut.
7
New England Research Institutes, Incorporated, Watertown, Massachusetts.
8
University of Alabama at Birmingham, Birmingham, Alabama.
9
Mayo Clinic, Rochester, Minnesota.
10
Icahn School of Medicine at Mount Sinai, New York, New York.

Abstract

BACKGROUND:

There are scant outcomes data in patients with type 2 diabetes and stable coronary artery disease (CAD) stratified by detailed angiographic burden of CAD or left ventricular ejection fraction (LVEF).

OBJECTIVES:

This study determined the effect of optimal medical therapy (OMT), with or without percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), on long-term outcomes with respect to LVEF and number of diseased vessels, including proximal left anterior descending artery involvement.

METHODS:

A patient-level pooled analysis was undertaken in 3 federally-funded trials. The primary endpoint was the composite of death, myocardial infarction (MI), or stroke, adjusted for trial and randomization strategy.

RESULTS:

Among 5,034 subjects, 15% had LVEF <50%, 77% had multivessel CAD, and 28% had proximal left anterior descending artery involvement. During a median 4.5-year follow-up, CABG + OMT was superior to PCI + OMT for the primary endpoint (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.59 to 0.85; p = 0.0002), death (HR: 0.76; 95% CI: 0.60 to 0.96; p = 0.024), and MI (HR: 0.50; 95% CI: 0.38 to 0.67; p = 0.0001), but not stroke (HR: 1.54; 95% CI: 0.96 to 2.48; p = 0.074). CABG + OMT was also superior to OMT alone for prevention of the primary endpoint (HR: 0.79; 95% CI: 0.64 to 0.97; p = 0.022) and MI (HR: 0.55; 95% CI: 0.41 to 0.74; p = 0.0001), and was superior to PCI + OMT for the primary endpoint in patients with 3-vessel CAD (HR: 0.72; 95% CI: 0.58 to 0.89; p = 0.002) and normal LVEF (HR: 0.71; 95% CI: 0.58 to 0.87; p = 0.0012). There were no significant differences in OMT versus PCI + OMT.

CONCLUSIONS:

CABG + OMT reduced the primary endpoint during long-term follow-up in patients with type 2 diabetes and stable CAD, supporting this as the preferred management strategy.

KEYWORDS:

coronary artery bypass grafting; optimal medical therapy; percutaneous coronary intervention; stable ischemic heart disease

PMID:
27585501
DOI:
10.1016/j.jacc.2016.06.021
[Indexed for MEDLINE]
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