Revascularization Strategies for Patients With Coronary Artery Disease and Diabetes

Only about one-third of patients with diabetes and multivessel coronary artery disease (CAD) who present with non-ST-segment elevation myocardial infarction (NSTEMI) undergo coronary artery bypass graft (CABG) surgery, according to a study published in Circulation: Cardiovascular Quality and Outcomes.

In contrast, the use of percutaneous coronary intervention (PCI) has increased over the years.

Researchers collected patient information from the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network Registry—Get with the Guidelines (ACTION Registry—GWTG). The total population included 29 769 patients (539 hospitals) who presented with NSTEMI between 2008 and 2014 and had an angiography demonstrating multivessel CAD. Patients were grouped into 3 categories: CABG vs PCI vs no-revascularization. A small number (2%) received both CABG and PCI and thus were considered “treated with CABG.”

Fewer patients were treated with CABG (36.4%) compared to PCI (46.2%, with 77.2% treated with at least 1 drug-eluting stent), and 17.3% were treated without revascularization. Of the 312 hospitals included in the primary analysis cohort, there was a wide variation of use between CABG and PCI (CABG range=0% to 78%; PCI range=22% to 100%; P<.0001 for both).

Researchers also observed variation in use of CABG and PCI among subgroups as defined by CAD severity. “Among high-risk patients (3-vessel CAD and left main artery or pLAD [proximal left anterior descending] involvement), CABG has been the revascularization strategy of choice throughout the study period,” the authors noted. “Similarly, PCI is the preferred revascularization strategy among lower-risk patients (2-vessel CAD with pLAD involvement) with no significant change over time.”

“Furthermore, the proportional site-specific variability in use of CABG in the high-risk subgroup (3-vessel CAD with pLAD) and PCI in the low-risk subgroup (2-vessel CAD without pLAD) is lower when compared with the overall population (CABG range of 45% to 96% in high-risk group vs 0% to 78% in the overall cohort; PCI range of 51% to 98% in the low-risk subgroup vs 22% to 100% in the overall population).”

Factors associated with a greater likelihood of CABG vs PCI included left main artery or pLAD stenosis, signs of heart failure and elevated heart rate, mild to moderate left ventricular dysfunction, and increasing age (in patients less than 72 years of age).

Meanwhile, factors associated with a lower likelihood of CABG were early use of adenosine diphosphate receptor antagonists (eg, clopidogrel or prasugrel), female sex, history of smoking, prior MI, prior heart failure, current dialysis, higher body mass index (in overweight and obese patients), increasing age (in patients older than 72 years of age), and Medicare insurance coverage (vs HMO or private insurance).

Further research into this high-risk patient population is necessary so that clinicians can make informed decisions regarding revascularization strategies.

Reference

Pandey A, McGuire DK, de Lemos JA, et al. Revascularization trends in patients with diabetes mellitus and multivessel coronary artery disease presenting with non-ST elevation myocardial infarction. Insights from the NCDR ACTION Registry-GWTG. Circ Cardivasc Qual Outcomes. 2016. doi: 10.1161/CIRCOUTCOMES.115.002084.