https://diabetes.acponline.org/archives/2016/09/16/1.htm

CABG may improve outcomes compared with PCI in patients with diabetes and stable CAD

The results support coronary artery bypass grafting (CABG) with optimal medical therapy as the preferred management strategy, with optimal medical therapy alone as the next best therapeutic approach, the study authors said.


Coronary artery bypass grafting (CABG) reduced a composite of death, myocardial infarction (MI), or stroke compared with percutaneous coronary intervention (PCI) in patients with type 2 diabetes and stable coronary artery disease (CAD), a study found.

The study examined the effect of optimal medical therapy (OMT) with or without PCI or CABG on long-term outcomes, stratified by detailed angiographic burden of CAD or left ventricular ejection fraction (LVEF) and number of diseased vessels, including proximal left anterior descending artery involvement.

The patient-level pooled analysis used data from 3 federally funded trials. The primary end point was the composite of death, MI, or stroke, adjusted for trial and randomization strategy. Among 5,034 subjects, 15% had LVEF below 50%, 77% had multivessel CAD, and 28% had proximal left anterior descending artery involvement. Results appeared in the Sept. 6 Journal of the American College of Cardiology.

During a median 4.5-year follow-up, CABG with OMT was superior to PCI with OMT for the primary end point (hazard ratio [HR], 0.71; 95% CI, 0.59 to 0.85; P=0.0002), death (HR, 0.76; 95% CI, 0.60 to 0.96; P=0.024), and MI (HR, 0.50; 95% CI, 0.38 to 0.67; P=0.0001), but not stroke (HR, 1.54; 95% CI, 0.96 to 2.48; P=0.074). CABG with OMT was also superior to OMT alone for prevention of the primary end point (HR, 0.79; 95% CI, 0.64 to 0.97; P=0.022) and MI (HR, 0.55; 95% CI, 0.41 to 0.74; P=0.0001). CABG with OMT was superior to PCI with OMT for the primary end point in patients with 3-vessel CAD (HR, 0.72; 95% CI, 0.58 to 0.89; P=0.002) and normal LVEF (HR, 0.71; 95% CI, 0.58 to 0.87; P=0.0012). There were no significant differences in outcomes when OMT alone was compared to PCI with OMT.

Results support CABG with OMT as the preferred management strategy, the authors noted. “In the presence of factors that preclude a CABG + OMT strategy, we provide strong evidence to support OMT alone as the next best therapeutic approach. When such patients do not achieve sufficient control of angina or an adequate quality of life with OMT alone, PCI + OMT should be considered an appropriate therapeutic option,” they wrote.

An editorial noted that the superiority of CABG with OMT over OMT alone is driven by 1 study that included only 763 patients. The editorialist noted 2 trials (ISCHEMIA and ISCHEMIA-CKD) are currently underway that will also provide important insights about treatment options in this population. “Until the results of these clinical trials are available, the choice between the 3 therapies should be on the basis of the pros and cons of each approach, ability to achieve complete revascularization with PCI, and patient preference,” the editorialist wrote.