Author + information
- Received June 11, 2018
- Revision received November 8, 2018
- Accepted November 12, 2018
- Published online January 28, 2019.
- Michael E. Farkouh, MD, MSca,∗ (, )@PMunkCardiacCtr,
- Mandeep S. Sidhu, MDb,
- Maria M. Brooks, PhDc,
- Helen Vlachos, MScc,
- William E. Boden, MDd,
- Robert L. Frye, MDe,
- Pamela Hartigan, PhDf,
- F.S. Siami, MPHg,
- Vera A. Bittner, MDh,
- Bernard R. Chaitman, MDi,
- G.B. John Mancini, MDj and
- Valentin Fuster, MD, PhDk,l
- aPeter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
- bAlbany Medical College, Albany, New York
- cUniversity of Pittsburgh, Pittsburgh, Pennsylvania
- dBoston University and VA New England Health Care System, Boston, Massachusetts
- eMayo Clinic, Rochester, Minnesota
- fYale University and VA West Haven, West Haven, Connecticut
- gNew England Research Institutes, Watertown, Massachusetts
- hUniversity of Alabama at Birmingham, Birmingham, Alabama
- iSt. Louis University, St. Louis, Missouri
- jUniversity of British Columbia, Vancouver, British Columbia, Canada
- kIcahn School of Medicine at Mount Sinai, New York, New York
- lCentro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- ↵∗Address for correspondence:
Dr. Michael E. Farkouh, Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, 585 University Avenue, 4N474, Toronto, Ontario M5G 2N2, Canada.
Background The optimal coronary revascularization strategy in patients with stable ischemic heart disease (SIHD) who have type 2 diabetes (T2DM) and chronic kidney disease (CKD) remains unclear.
Objectives This patient-level pooled analysis sought to compare outcomes of 3 large, federally-funded randomized trials in SIHD patients with T2DM and CKD (COURAGE [Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation], BARI 2D [Bypass Angioplasty Revascularization Investigation 2 Diabetes], and FREEDOM [Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-vessel Disease]).
Methods The primary endpoint was the composite of major adverse cardiovascular or cerebrovascular events (MACCE) including all-cause death, myocardial infarction (MI), or stroke adjusted for trial and randomization strategy.
Results Of the 4,953 patients with available estimated glomerular filtration rate (eGFR) at baseline, 1,058 had CKD (21.4%). CKD patients were more likely to be older, be female, and have a history of heart failure. CKD subjects were more likely to experience a MACCE (adjusted hazard ratio [HR]: 1.48; 95% confidence interval [CI]: 1.28 to 1.71; p = 0.0001) during a median 4.5-year follow-up. Both mild (eGFR 45 to 60 ml/min/1.73 m2) and moderate to severe (eGFR <45 ml/min/1.73 m2) CKD predicted MACCE (adjusted HRs: 1.25 and 2.26, respectively). For patients without CKD, coronary artery bypass graft (CABG) surgery combined with optimal medical therapy (OMT) was associated with lower MACCE rates compared with percutaneous coronary intervention (PCI) + OMT (adjusted HR: 0.69; 95% CI: 0.55 to 0.86; p = 0.001). For the comparison of CABG + OMT versus PCI + OMT in the CKD group, there was only a statistically significant difference in subsequent revascularization rates (HR: 0.25; 95% CI: 0.15 to 0.41; p = 0.0001) but not in MACCE rates.
Conclusions Among SIHD patients with T2DM and no CKD, CABG + OMT significantly reduced MACCE compared with PCI + OMT. In subjects with CKD, there was a nonsignificant trend toward a better MACCE outcome with CABG and a significant reduction in subsequent revascularization.
This study was supported by a grant from Gilead Sciences (to Dr. Brooks). Gilead Sciences played no role in developing the questions explored, study design, collection of data, methods, analyses, interpretation of results, or writing of the paper. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received June 11, 2018.
- Revision received November 8, 2018.
- Accepted November 12, 2018.
- 2019 American College of Cardiology Foundation
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