NEW YORK (Reuters Health) – A coronary artery bypass graft (CABG) is the best choice for patients with multivessel coronary artery disease who are also diabetic, according to new research.
Among percutaneous coronary intervention (PCI) choices, sirolimus-eluting stents, or SES, beat out bare-metal stents, or BMS, at preventing heart attacks and other cardiovascular and cerebrovascular events.
The analysis, led by Dr. Yoshinobu Onuma of the Erasmus Medical Center in Rotterdam, included 367 patients with diabetes and multivessel disease who were part of one of two Dutch studies, Arterial Revascularization Therapy Study I and II (ARTS I and II).
Patients in ARTS I had been randomly assigned to treatment with BMS or CABG, while all patients in ARTS II had received SES. Five years later, investigators interviewed all patients over the phone about their medical history post-procedure, also consulting with patients’ physicians when necessary.
In total, the 5-year outcomes of 112 diabetic patients treated with BMS, 96 with CABG, and 159 with SES were analyzed. Primary endpoints were death, stroke, heart attack, and need for repeat revascularization.
While a three-year follow-up had not found a significant difference in adverse events between patients treated with SES and CABG, by five years SES patients had significantly higher rates of a composite of death, stroke, heart attack, or repeat revascularization. But patients who had BMS were generally the worst off.
Diabetic patients who received BMS had higher rates of heart attack (11% vs. 4.8% for SES and 5.2% for CABG) and any major adverse cardiovascular or cerebrovascular event (53.6% vs. 40.5% for SES and 23.4% for CABG.) The chance of dying from any cause was not significantly different between the three patient groups, however.
Rates of repeat revascularization were also highest in patients treated with BMS (43.7%), and lowest in those who received CABG (10.7%). After SES, there was a 33.2% rate of revascularization.
The authors point out that a 5-year difference between when the ARTS I and ARTS II studies were conducted could have biased the results in favor of SES because of a general decrease in surgery-related deaths over that span.
Sill, the hazard ratios “suggest and advantage of CABG over SES in reducing repeat revascularization procedures but equivalence of the 2 procedures in terms of mortality and MI risk,” the authors wrote in JACC: Cardiovascular Interventions.
They conclude, “At 5-year follow-up, CABG seems to have better outcomes than PCI in a diabetic patient population by virtue of reducing repeat revascularization rates, making CABG the preferred treatment for this subgroup of patients with MVD.”
In an accompanying editorial, Dr. Koon-Hu Mak of Gleneagles Medical Center in Singapore pointed out that many patients “have a natural distaste for surgery” and that data from the ARTS studies suggest that DES might have avoided CABG in 96.2% of patients.
J Am Coll Cardiol Intv
