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J Am Coll Cardiol. 2017 Dec 19;70(24):2995-3006. doi: 10.1016/j.jacc.2017.10.029.

Surgical Versus Percutaneous Coronary Revascularization in Patients With Diabetes and Acute Coronary Syndromes.

Author information

1
University of British Columbia, Vancouver, Canada. Electronic address: kramanathan@providencehealth.bc.ca.
2
University of British Columbia, Vancouver, Canada.
3
BC Centre for Improved Cardiovascular Health, Vancouver, Canada.
4
Loyola University Medical Center and Stritch School of Medicine, Maywood, Illinois.
5
Cardiac Services British Columbia, Vancouver, Canada.
6
St. Michael's Hospital, Toronto, Canada.
7
University of British Columbia, Vancouver, Canada; BC Centre for Improved Cardiovascular Health, Vancouver, Canada.
8
Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada.

Abstract

BACKGROUND:

Randomized trial data support the superiority of coronary artery bypass grafting (CABG) surgery over percutaneous coronary intervention (PCI) in diabetic patients with multivessel coronary artery disease (MV-CAD). However, whether this benefit is seen in a real-world population among subjects with stable ischemic heart disease (SIHD) and acute coronary syndromes (ACS) is unknown.

OBJECTIVES:

The main objective of this study was to assess the generalizability of the FREEDOM (Future REvascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-vessel Disease) trial in real-world practice among patients with diabetes mellitus and MV-CAD in residents of British Columbia, Canada. Additionally, the study evaluated the impact of mode of revascularization (CABG vs. PCI with drug-eluting stents) in diabetic patients with ACS and MV-CAD.

METHODS:

In a large population-based database from British Columbia, this study evaluated major cardiovascular outcomes in all diabetic patients who underwent coronary revascularization between 2007 and 2014 (n = 4,661, 2,947 patients with ACS). The primary endpoint (major adverse cardiac or cerebrovascular events [MACCE]) was a composite of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. The risk of MACCE with CABG or PCI was compared using multivariable adjustment and a propensity score model.

RESULTS:

At 30-days post-revascularization, for ACS patients the odds ratio for MACCE favored CABG 0.49 (95% confidence interval [CI]: 0.34 to 0.71), whereas among SIHD patients MACCE was not affected by revascularization strategy (odds ratio: 1.46; 95% CI: 0.71 to 3.01; pinteraction <0.01). With a median follow-up of 3.3 years, the late (31-day to 5-year) benefit of CABG over PCI no longer varied by acuity of presentation, with a hazard ratio for MACCE in ACS patients of 0.67 (95% CI: 0.55 to 0.81) and the hazard ratio for SIHD patients of 0.55 (95% CI: 0.40 to 0.74; pinteraction = 0.28).

CONCLUSIONS:

In diabetic patients with MV-CAD, CABG was associated with a lower rate of long-term MACCE relative to PCI for both ACS and SIHD. A well-powered randomized trial of CABG versus PCI in the ACS population is warranted because these patients have been largely excluded from prior trials.

KEYWORDS:

diabetes; multivessel coronary artery disease; revascularization; survival

PMID:
29241487
DOI:
10.1016/j.jacc.2017.10.029
[Indexed for MEDLINE]

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