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Decade Long Temporal Trends in Revascularization for Patients With Diabetes Mellitus (From the Northern New England
Jan H Denkmann1, David J Malenka2, Niveditta Ramkumar2
1University of Vermont Medical Center, Burlington, Vermont.
Insights
The FREEDOM trial showed coronary artery bypass grafting (CABG) superiority for diabetes patients with multivessel coronary artery disease (MV CAD). However, clinical practice did not change post-trial, with CABG remaining the preferred strategy for 3-vessel CAD.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Practice Research
Background:
- The FREEDOM trial established coronary artery bypass grafting (CABG) superiority over percutaneous coronary intervention with drug-eluting stents (PCI-DES) for diabetes mellitus (DM) patients with multivessel coronary artery disease (MV CAD).
- Understanding the impact of this landmark trial on real-world clinical decision-making is crucial for optimizing patient care.
Purpose of the Study:
- To evaluate the influence of the FREEDOM trial findings on the adoption of CABG versus PCI-DES strategies in patients with coronary artery disease (CAD) and MV CAD.
- To identify factors associated with the choice of revascularization strategy and analyze hospital outcomes before and after the trial publication.
Main Methods:
- A retrospective study analyzed 6,985 patients with concomitant CAD and MV CAD across 7 centers, comparing data from 2008-2012 (pre-trial) and 2013-2017 (post-trial).
- Multivariable mixed-effects logistic regression identified risk factors for choosing CABG versus PCI-DES, particularly in patients with 3-vessel CAD (3V CAD).
Main Results:
- PCI-DES was favored for 2-vessel CAD, but CABG predominated (72%) for 3V CAD patients, with a stable CABG to PCI-DES ratio (2.47) throughout the decade.
- The FREEDOM trial publication did not significantly alter the revascularization strategy, as indicated by an adjusted odds ratio of 1.01 for CABG versus PCI post-trial.
- Independent predictors for CABG in DM patients with 3V CAD included peripheral arterial disease; predictors for PCI included female sex and age ≥75.
Conclusions:
- Despite the FREEDOM trial's evidence, clinical practice regarding revascularization for diabetes patients with 3V CAD remained largely unchanged, with CABG being the predominant strategy.
- Significant center-based variability exists in the choice between CABG and PCI, highlighting potential regional or institutional practice patterns.
- Factors such as comorbidities and patient demographics influence revascularization decisions, underscoring the need for personalized treatment approaches in MV CAD management.
Abstract:
The FREEDOM trial demonstrated superiority of coronary artery bypass grafting (CABG) for patients with diabetes mellitus (DM) and multivessel coronary artery disease (MV CAD) as compared to percutaneous coronary intervention (PCI) with drug eluting stent (PCI-DES). We sought to study the impact of the FREEDOM trial on clinical practice. We studied trends in the use of CABG vs. PCI and factors associated with revascularization strategy among 6,985 patients with concomitant CAD and MV CAD at 7 centers pre- and post-trial (2008-2012 vs. 2013-2017) as well as hospital outcomes. Multivariable mixed effects logistic regression was performed to identify risk factors associated with choice of revascularization strategy among the patients with 3-vessel CAD (3V CAD). 41% of patients had 3V CAD and 18% were ≥75 years of age. While PCI-DES was the preferred strategy in 2-vessel CAD (2V CAD), 72% of patients with 3V CAD underwent CABG. For patients with 3V CAD, the ratio of CABG to PCI-DES procedures was 2.47 over the decade and did not differ pre- and post-trial (adjusted odds ratio (OR) for CABG (vs. PCI) 1.01, 95% confidence interval (CI) 0.84-1.20). Independent risk factors of CABG among patients with DM and 3V CAD included peripheral arterial disease and absence of prior myocardial infarction and prior PCI. The risk factors for PCI were female sex (OR 0.60, 95% CI 0.50-0.73, p<0.001) and age ≥75 (OR 0.50, 95% CI 0.35-0.72, p<0.001). Center based variability was observed for CABG vs. PCI (center effect, rho=14%, p<0.001). In conclusion, PCI-DES is the preferred strategy for DM patients with MV CAD. Yet, among those with 3V CAD, CABG was chosen in ¾ of patients with no change in clinical practice related to the publication of the FREEDOM trial.