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Strategies for Multivessel Revascularization in Patients With Diabetes
Study Questions:
What is the optimal revascularization strategy in diabetic patients with multivessel coronary artery disease?
Methods:
The authors randomized 1,900 patients with diabetes and multivessel coronary artery disease to percutaneous coronary intervention (PCI) with drug-eluting stents or coronary artery bypass grafting (CABG). All patients received optimal medical therapy and good risk factor control. The primary endpoint was a composite of all-cause death, myocardial infarction, or stroke.
Results:
The study enrolled 1,900 patients across 140 centers from 2005 through 2010. The average age of the cohort was 63 years, 29% were female, and three-vessel coronary artery disease was seen in 83%. The median follow-up among survivors was 3.8 years. The primary outcome occurred in 18.7% of the patients in the CABG arm compared with 26.6% of the patients in PCI arm (p = 0.005). CABG was associated with lower rates of myocardial infarction (6% vs. 13.9%, p < 0.001) or death (10.9% vs. 16.3%, p = 0.049) at 5 years with an increase in risk of stroke (5.2% vs. 2.4%, p = 0.03). The superiority of CABG was maintained irrespective of the type of stent used (sirolimus-eluting versus paclitaxel-eluting) or the SYNTAX score.
Conclusions:
Among diabetic patients with multivessel disease, CABG was associated with a superior outcome compared with PCI.
Perspective:
This important study establishes the pre-eminence of CABG as the preferred revascularization strategy in diabetic patients with multivessel disease. The superiority of CABG over PCI was first demonstrated in the angioplasty era (BARI), confirmed in the stent era (Hlatky, Lancet 2009), and has now been re-established in contemporary practice. CABG bypasses the vulnerable plaque that is mostly located in the proximal vessels, thereby protecting against myocardial infarction. The hope was that plaque passivation with aggressive medical therapy combined with relief of ischemia with PCI would provide benefits similar to CABG, but FREEDOM suggests that the infarction risk still remains high with the former strategy. CABG should remain the preferred therapy for diabetic patients with multivessel CAD, and PCI should be reserved for select patients where CABG is not a viable option.
Keywords: Coronary Artery Disease, Stroke, Cost-Benefit Analysis, Myocardial Infarction, Follow-Up Studies, Drug-Eluting Stents, Risk Factors, Sirolimus, Angioplasty, Percutaneous Coronary Intervention, Paclitaxel, Cardiology, Coronary Artery Bypass, Diabetes Mellitus
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