Review: In diabetes with multivessel or left main CAD, PCI increases death/MI/stroke combo compared with CABG

In patients with diabetes and multivessel disease or left main coronary artery disease (CAD), percutaneous coronary intervention (PCI) was associated with a higher rate of death, myocardial infarction (MI), or stroke than coronary artery bypass grafting (CABG), a meta-analysis found. The included studies looked at PCI with bare-metal stents (BMSs) or drug-eluting stents (DESs).

The meta-analysis was published in the Nov. 18, 2014, Annals of Internal Medicine and summarized in the December 2014 ACP Diabetes Monthly. The following commentary by Mark A. Hlatky, MD, was published in the ACP Journal Club section of the March 17, 2015, Annals of Internal Medicine.

PCI and CABG are alternative methods to revascularize patients with multivessel CAD, and their outcomes have been compared in many studies over the past 25 years. Patient factors and procedural details might modify the comparative effectiveness of PCI and CABG. Tu and colleagues focused on an important population subgroup (patients with diabetes) and a specific method of revascularization (PCI-DES). Their analysis included not only head-to-head randomized trials that directly compared PCI-DES with CABG in patients with diabetes, but also trials of PCI-BMS vs CABG, and PCI-DES vs PCI-BMS. The results of their Bayesian network analysis shows a 33% higher rate of death, MI, or stroke after PCI than after CABG. This is consistent with results of conventional meta-analysis of the head-to-head trials, and of the largest single study included in the analysis, the FREEDOM trial.

Although the composite endpoint favored CABG, fewer strokes but more deaths occurred after PCI-DES. A well-informed patient may be more worried about stroke than death and choose PCI-DES over CABG. In addition, the expected increase in life expectancy after CABG vs PCI varies considerably among patients with diabetes, so individualizing treatment recommendations is important.

Tu and colleagues also found that the comparative effectiveness of CABG and PCI was not affected by stent type (BMS or DES), which is similar to a recent study based on Medicare patients. This suggests that the benefit of CABG in patients with diabetes will probably hold up even with newer types of stents for PCI.