Mortality After Multivessel Revascularization in Patients With Diabetes and Acute Coronary Syndromes
Lucas C Godoy1,2,3,4, Michael E Farkouh1,5, Peter C Austin2,3
1Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
Insights
Coronary artery bypass grafting (CABG) reduced mortality in diabetic NSTEMI patients compared to percutaneous coronary intervention (PCI). This benefit was significant only for patients deemed potentially ineligible for CABG after surgical consultation.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Optimal revascularization strategy remains unclear for diabetic patients with multivessel disease and non-ST-segment elevation myocardial infarction (NSTEMI).
- Comparing coronary artery bypass grafting (CABG) versus multivessel percutaneous coronary intervention (PCI) is crucial for this high-risk population.
Purpose of the Study:
- To compare all-cause mortality between CABG and multivessel PCI in diabetic patients experiencing NSTEMI.
- To evaluate the impact of surgical consultation on treatment outcomes.
Main Methods:
- Retrospective cohort study of 4,649 CABG and 6,760 PCI patients in Ontario, Canada (April 2009-March 2020).
- Exclusion criteria included prior CABG/PCI and shock.
- Propensity score matching was employed to balance covariates.
- Patients receiving PCI after a cardiac surgeon consultation were analyzed separately.
Main Results:
- Over a median of 5.5 years, CABG was associated with reduced all-cause mortality versus PCI (5-year estimates: 23.4% vs 26.5%; HR 0.89).
- No significant mortality difference was found between CABG and PCI in patients without a surgical consultation.
- CABG showed significantly reduced mortality compared to PCI in patients who had a pre-procedure surgical consultation (HR 0.72).
Conclusions:
- Coronary artery bypass grafting (CABG) demonstrates a mortality benefit over multivessel percutaneous coronary intervention (PCI) in diabetic patients with non-ST-segment elevation myocardial infarction (NSTEMI).
- This survival advantage is primarily observed in patients who undergo a surgical consultation and are potentially ineligible for CABG, suggesting careful patient selection is key.
Background:
The optimal revascularization strategy in patients with diabetes and multivessel disease in the setting of a non-ST-segment elevation myocardial infarction (NSTEMI) is unknown.
Objectives:
The purpose of this study was to compare all-cause mortality between coronary artery bypass grafting (CABG) and multivessel percutaneous coronary intervention (PCI) among patients with diabetes and NSTEMI.
Methods:
All patients with diabetes and multivessel disease admitted for NSTEMI in Ontario, Canada, between April 2009 and March 2020 were included. Those with previous CABG, PCI in the previous 90 days, or shock were excluded. The primary outcome was all-cause mortality. Propensity score matching was used to account for confounding. Patients who had a cardiac surgeon consultation and then received PCI were classified as being potentially ineligible for CABG.
Results:
The cohort included 4,649 CABG and 6,760 PCI patients (mean age: 67.8 ± 11.5 years; 70.4% males), resulting in 2,385 matched pairs. CABG was associated with reduced all-cause mortality compared to PCI over a median follow-up of 5.5 years (5-year estimates: 23.4% vs 26.5%; HR: 0.89; 95% CI: 0.80-0.98; P = 0.021). However, no significant differences in mortality were observed between CABG and PCI patients without a surgical consultation (2,130 pairs; HR: 0.97; 95% CI: 0.86-1.08), while CABG was associated with reduced mortality when compared against PCI patients who had received a surgical consultation (388 pairs; HR: 0.72; 95% CI: 0.58-0.88; P = 0.002).
Conclusions:
While CABG was associated with reduced all-cause mortality compared to multivessel PCI in patients with diabetes and NSTEMI, CABG benefit was seen only against PCI patients potentially ineligible for CABG after receiving a preprocedure surgical consultation.
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