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Surgical Versus Percutaneous Coronary Revascularization in Patients With Diabetes and Acute Coronary Syndromes
Krishnan Ramanathan1, James G Abel1, Julie E Park2
1University of British Columbia, Vancouver, Canada.
Insights
Coronary artery bypass grafting (CABG) surgery is superior to percutaneous coronary intervention (PCI) for diabetic patients with multivessel coronary artery disease (MV-CAD). This real-world study confirms CABG reduces major adverse cardiac or cerebrovascular events (MACCE) in both acute coronary syndromes (ACS) and stable ischemic heart disease (SIHD) patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Randomized trials show coronary artery bypass grafting (CABG) superiority over percutaneous coronary intervention (PCI) for diabetic patients with multivessel coronary artery disease (MV-CAD).
- Real-world evidence is lacking for diabetic patients with stable ischemic heart disease (SIHD) and acute coronary syndromes (ACS) and MV-CAD.
Purpose of the Study:
- To assess the generalizability of the FREEDOM trial in a real-world population of diabetic patients with MV-CAD in British Columbia.
- To evaluate the comparative effectiveness of CABG versus PCI with drug-eluting stents in diabetic patients with MV-CAD, stratified by ACS and SIHD.
Main Methods:
- A population-based study of 4,661 diabetic patients (2,947 with ACS) who underwent coronary revascularization between 2007 and 2014.
- The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE), a composite of all-cause death, nonfatal myocardial infarction, and nonfatal stroke.
- Multivariable adjustment and propensity score modeling were used to compare MACCE risk between CABG and PCI.
Main Results:
- At 30 days, CABG significantly favored PCI for ACS patients (OR 0.49; 95% CI: 0.34-0.71), but not for SIHD patients (OR 1.46; 95% CI: 0.71-3.01).
- Over a median follow-up of 3.3 years, CABG demonstrated a long-term benefit over PCI for both ACS (HR 0.67; 95% CI: 0.55-0.81) and SIHD patients (HR 0.55; 95% CI: 0.40-0.74).
- The long-term benefit of CABG did not significantly vary by acuity of presentation (pinteraction = 0.28).
Conclusions:
- In diabetic patients with MV-CAD, CABG is associated with lower long-term MACCE rates compared to PCI for both ACS and SIHD.
- The findings support the generalizability of randomized trial results to real-world practice.
- A well-powered randomized trial in the ACS population is warranted due to their exclusion from prior trials.
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.
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