Multivessel CAD With Diabetes: Choosing an Optimal Revascularization Strategy

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At 30 days, the odds ratio for MACCE favored CABG over PCI in patients with ACS.
At 30 days, the odds ratio for MACCE favored CABG over PCI in patients with ACS.

Coronary artery bypass grafting (CABG) surgery is associated with lower rates of long-term major adverse cardiac or cerebrovascular events (MACCE) than percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) in patients with diabetes with multivessel coronary artery disease (CAD), according to study findings published in the Journal of the American College of Cardiology.1

Researchers obtained data from patients with diabetes in British Columbia who underwent coronary revascularization between 2007 and 2014. A total of 2888 PCI procedures and 1931 CABG procedures were included in the analysis. In addition, 3017 patients had ACS and 1802 patients had stable ischemic heart disease. The primary end point for this analysis was a composite of all-cause death, nonfatal myocardial infarction, and nonfatal stroke.

 

The odds ratio for MACCE in patients with ACS favored CABG over PCI at 30 days following revascularization (odds ratio [OR] 0.49; 95% CI, 0.34-0.71). In patients with stable ischemic heart disease, revascularization strategy did not significantly affect MACCE rates (OR 1.46; 95% CI, 0.71-3.01).

Although the effect of the revascularization strategy on MACCE rates varied by the presentation of either ACS or stable ischemic heart disease (Pinteraction<.01) at 30 days, the 31-day and 5-year advantage of CABG vs PCI did not significantly vary. At median follow-up of 3.3 years, the hazard ratio for MACCE in patients with ACS was 0.67 (95% CI, 0.55-0.81) vs 0.55 (95% CI, 0.40-0.74) in patients with stable ischemic heart disease.

The observational design and the limited available data on background therapy among patients in this study represent possible limitations to the findings. In addition, the investigators did not determine complexity of patients' disease or the completeness of revascularization, further limiting the findings' clinical relevance.

 

Despite the limitations, the early and late benefits of CABG vs PCI in patients with ACS suggest “further gains may be made by moving beyond ad hoc PCI as the default procedure in diabetic patients with [multivessel] CAD.”

Reference

Ramanathan K, Abel JG, Park JE, et al. Surgical versus percutaneous coronary revascularization in patients with diabetes and acute coronary syndromes. J Am Coll Cardiol. 2017;70(24):2995-3006.

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