Author + information
- Received October 21, 2016
- Revision received September 29, 2017
- Accepted October 10, 2017
- Published online December 11, 2017.
- Krishnan Ramanathan, MB, ChBa,∗ (, )
- James G. Abel, MDa,
- Julie E. Park, Mmathb,
- Anthony Fung, MBBSa,
- Verghese Mathew, MDc,
- Carolyn M. Taylor, MDa,
- G.B. John Mancini, MDa,
- Min Gao, MD, PhDb,
- Lillian Ding, MScd,
- Subodh Verma, MD, PhDe,
- Karin H. Humphries, DSca,b and
- Michael E. Farkouh, MD, MScf
- aUniversity of British Columbia, Vancouver, Canada
- bBC Centre for Improved Cardiovascular Health, Vancouver, Canada
- cLoyola University Medical Center and Stritch School of Medicine, Maywood, Illinois
- dCardiac Services British Columbia, Vancouver, Canada
- eSt. Michael’s Hospital, Toronto, Canada
- fPeter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada
- ↵∗Address for correspondence:
Dr. Krishnan Ramanathan, University of British Columbia, 1081 Burrard St – B475, Vancouver, BC V6Z 1Y6, Canada.
Background Randomized trial data support the superiority of coronary artery bypass grafting (CABG) surgery over percutaneous coronary intervention (PCI) in diabetic patients with multivessel coronary artery disease (MV-CAD). However, whether this benefit is seen in a real-world population among subjects with stable ischemic heart disease (SIHD) and acute coronary syndromes (ACS) is unknown.
Objectives The main objective of this study was to assess the generalizability of the FREEDOM (Future REvascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-vessel Disease) trial in real-world practice among patients with diabetes mellitus and MV-CAD in residents of British Columbia, Canada. Additionally, the study evaluated the impact of mode of revascularization (CABG vs. PCI with drug-eluting stents) in diabetic patients with ACS and MV-CAD.
Methods In a large population-based database from British Columbia, this study evaluated major cardiovascular outcomes in all diabetic patients who underwent coronary revascularization between 2007 and 2014 (n = 4,661, 2,947 patients with ACS). The primary endpoint (major adverse cardiac or cerebrovascular events [MACCE]) was a composite of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. The risk of MACCE with CABG or PCI was compared using multivariable adjustment and a propensity score model.
Results At 30-days post-revascularization, for ACS patients the odds ratio for MACCE favored CABG 0.49 (95% confidence interval [CI]: 0.34 to 0.71), whereas among SIHD patients MACCE was not affected by revascularization strategy (odds ratio: 1.46; 95% CI: 0.71 to 3.01; pinteraction <0.01). With a median follow-up of 3.3 years, the late (31-day to 5-year) benefit of CABG over PCI no longer varied by acuity of presentation, with a hazard ratio for MACCE in ACS patients of 0.67 (95% CI: 0.55 to 0.81) and the hazard ratio for SIHD patients of 0.55 (95% CI: 0.40 to 0.74; pinteraction = 0.28).
Conclusions In diabetic patients with MV-CAD, CABG was associated with a lower rate of long-term MACCE relative to PCI for both ACS and SIHD. A well-powered randomized trial of CABG versus PCI in the ACS population is warranted because these patients have been largely excluded from prior trials.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Sripal Bangalore, MD, MHA, served as Guest Editor for this paper.
Presented in part at the Annual Scientific Sessions of the American Heart Association, Orlando, Florida, November 2015.
- Received October 21, 2016.
- Revision received September 29, 2017.
- Accepted October 10, 2017.
- 2017 American College of Cardiology Foundation
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