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Trends in Guideline-Driven Revascularization in Diabetic Patients with Multivessel Coronary Heart Disease
Umme Rumana1,2, Richard Kones2, Montather O Taheer3
1The University of Texas Health Science Center at Houston (UTHealth) School of Biomedical Informatics, Houston, TX 77030, USA.
Insights
Coronary artery bypass grafting (CABG) remains recommended for diabetes patients with 3-vessel disease. A study found no significant change in the odds of receiving CABG versus percutaneous coronary intervention (PCI) after 2011 guidelines. This suggests modern practice considers patient choice and other factors in revascularization decisions.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Coronary artery bypass grafting (CABG) has a class I recommendation for diabetes patients with chronic ≥3 vessel disease per 2011 ACC/AHA guidelines.
- Existing literature primarily compares outcomes of CABG versus percutaneous coronary intervention (PCI), with limited data on procedure selection odds.
Purpose of the Study:
- To compare the odds of receiving CABG versus PCI in diabetes patients with chronic ≥3 vessel disease before and after the 2011 ACC/AHA guidelines.
- To identify factors influencing the choice between CABG and PCI in this high-risk patient population.
Main Methods:
- A secondary analysis of a de-identified database of 30,482 patients was conducted.
- Odds of CABG versus PCI were determined as the binary dependent variable in two periods: pre-guidelines (2009-2011) and post-guidelines (2013-2015).
- Logistic regression controlled for gender, ethnicity/race, and ischemic heart disease.
Main Results:
- The odds of CABG versus PCI in the post-guideline period were not statistically significantly different from the pre-guideline period (odds ratio = 0.98, 95% CI = 0.925-1.032, p=0.400).
- Ethnicity/race, gender, and heart disease significantly contributed to the prediction model (p < 0.05).
- No significant rise in CABG odds was observed in high-risk patients with diabetes and multivessel coronary heart disease post-guidelines.
Conclusions:
- Despite guidelines, the odds of undergoing CABG versus PCI did not significantly change among high-risk diabetes patients with multivessel disease.
- Modern revascularization decisions likely involve patient choice and additional variables beyond guideline recommendations.
- The reliability of procedure occurrence odds as a surrogate for provider guideline compliance remains uncertain.
Abstract:
In diabetes patients with chronic ≥3 vessel disease, coronary artery bypass grafting (CABG) holds a class I recommendation in the American College of Cardiology and American Heart Association (ACC/AHA) 2011 guidelines, and this classification has not changed to date. Much of the literature has focused upon whether CABG or percutaneous coronary intervention (PCI) produces better outcomes; there is a paucity of data comparing the odds of receiving these procedures. A secondary analysis was conducted in a de-identified database comprised of 30,482 patients satisfying the entry criteria. Odds of occurrence (CABG, PCI) were determined as the binary dependent variable in period 1, (17 October 2009 through 31 December 2011), and period 2 (1 January 2013 through 16 March 2015), before and after the 2011 guidelines, while controlling for gender, ethnicity/race, and ischemic heart disease as covariates. The odds of performing CABG rather than PCI in period 2 were not statistically significantly different than in period 1 (p = 0.400). The logistic regression model chi-square statistic was statistically significant, with χ2 (7) = 308.850, p < 0.0001. The Wald statistic showed that ethnicity/race (African American, Caucasian, Hispanic and Other), gender, and heart disease contributed significantly to the prediction model with p < 0.05, but ethnicity 'Unknown' did not. The odds of CABG versus PCI in period 2 were 0.98 times those in period 1 95% confidence interval (CI) = (0.925, 1.032), statistically controlling for covariates. There was no significant rise in the odds of undergoing a CABG among this dataset of high-risk patients with diabetes and multivessel coronary heart disease. Modern practice has evolved regarding patient choice and additional variables that impact the final revascularization method employed. The degree to which odds of occurrence of procedures are a reliable surrogate for provider compliance with guidelines remains uncertain.
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