Revascularization Strategies in Patients with Diabetes and Acute Coronary Syndromes

Mortality After Multivessel Revascularization in Patients With Diabetes and Acute Coronary Syndromes

Background

The optimal revascularization strategy in patients with diabetes and multivessel disease in the setting of a non-ST-segment elevation myocardial infarction (NSTEMI) is unknown.

Objectives

The purpose of this study was to compare all-cause mortality between coronary artery bypass grafting (CABG) and multivessel percutaneous coronary intervention (PCI) among patients with diabetes and NSTEMI.

Methods

All patients with diabetes and multivessel disease admitted for NSTEMI in Ontario, Canada, between April 2009 and March 2020 were included. Those with previous CABG, PCI in the previous 90 days, or shock were excluded. The primary outcome was all-cause mortality. Propensity score matching was used to account for confounding. Patients who had a cardiac surgeon consultation and then received PCI were classified as being potentially ineligible for CABG.

Results

The cohort included 4,649 CABG and 6,760 PCI patients (mean age: 67.8 ± 11.5 years; 70.4% males), resulting in 2,385 matched pairs. CABG was associated with reduced all-cause mortality compared to PCI over a median follow-up of 5.5 years (5-year estimates: 23.4% vs 26.5%; HR: 0.89; 95% CI: 0.80-0.98; P = 0.021). However, no significant differences in mortality were observed between CABG and PCI patients without a surgical consultation (2,130 pairs; HR: 0.97; 95% CI: 0.86-1.08), while CABG was associated with reduced mortality when compared against PCI patients who had received a surgical consultation (388 pairs; HR: 0.72; 95% CI: 0.58-0.88; P = 0.002).

Conclusions

While CABG was associated with reduced all-cause mortality compared to multivessel PCI in patients with diabetes and NSTEMI, CABG benefit was seen only against PCI patients potentially ineligible for CABG after receiving a preprocedure surgical consultation.

The efficacy of minimally invasive coronary artery bypass grafting (mics cabg) for patients with coronary artery diseases and diabetes: a single center retrospective study

BACKGROUND

conventional coronary artery bypass grafting (CCABG) tends to cause severe complications in patients with comorbid Coronary Artery Diseases (CAD) and diabetes. On the other hand, the Minimally Invasive Cardiac Surgery Coronary Artery Bypass Grafting (MICS CABG) via transthoracic incision is associated with rapid recovery and reduced complications. Adding to the limited literature, this study compares CCABG and MICS CABG in terms of efficacy and safety.

METHODS

Herein, 104 CCABG and MICS CABG cases (52 cases each) were included. The patients were recruited from the Minimally Invasive Cardiac Surgery Center, Anzhen Hospital, between January 2017 and December 2021 and were selected based on the Propensity Score Matching (PSM) model. The key outcomes included All-cause Death, Myocardial Infarction (MI), Cerebrovascular Events, revascularization, Adverse Wound Healing Events and one-year patency of the graft by coronary CTA.

RESULTS

Compared to CCABG, MICS CABG had longer surgical durations [4.25 (1.50) h vs.4.00 (1.13) h, P = 0.028], but showed a reduced intraoperative blood loss [600.00 (400.00) mL vs.700.00 (300.00) mL, P  = 0.032] and a lower secondary incision debridement and suturing rate (5.8% vs.19.2%, P = 0.038). In follow up, no statistically significant differences were found between the two groups in the cumulative Major Adverse Cardiovascular and Cerebrovascular Events (MACCEs) incidence (7.7% vs. 5.9%), all-cause mortality (0 vs. 0), MI incidence (1.9% vs. 2.0%), cerebral apoplexy incidence (5.8% vs. 3.9%), and repeated revascularization incidence (0 vs. 0) (P > 0.05). Additionally, coronary CTA results revealed that the two groups' one-year graft patency (94.2% vs. 90.2%, P = 0.761) showed no statistically significant difference.

CONCLUSION

In patients with comorbid CAD and diabetes, MICS CABG and CCABG had comparable revascularization performances. Moreover, MICS CABG can effectively reduce, if not prevent, poor clinical outcomes/complications, including incision healing, sternal infection and prolonged length of stay in diabetes patients.

An elevated triglyceride-glucose index predicts adverse outcomes and interacts with the treatment strategy in patients with three-vessel disease

BACKGROUND

Insulin resistance is a pivotal risk factor for cardiovascular diseases, and the triglyceride-glucose (TyG) index is a well-established surrogate of insulin resistance. This study aimed to investigate the prognostic value of the TyG index and its ability in therapy guidance in patients with three-vessel disease (TVD).

METHODS

A total of 8862 patients with TVD with available baseline TyG index data were included in the study. The endpoint was major adverse cardiac events (MACE). All patients received coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or medical therapy (MT) alone reasonably.

RESULTS

An elevated TyG index was defined as the TyG index greater than 9.51. During a median follow-up of 7.5 years, an elevated TyG index was significantly associated with an increased risk of MACE (adjusted hazard ratio 1.161, 95% confidence interval 1.026-1.314, p = 0.018). The elevated TyG index was shown to have a more pronounced predictive value for MACE in patients with diabetes, but failed to predict MACE among those without diabetes, whether they presented with stable angina pectoris (SAP) or acute coronary syndrome (ACS). Meanwhile, the association between an elevated TyG index and MACE was also found in patients with left main involvement. Notably, CABG conferred a significant survival advantage over PCI in patients with a normal TyG index, but was not observed to be superior to PCI in patients with an elevated TyG index unless the patients had both ACS and diabetes. In addition, the benefit was shown to be similar between MT and revascularisation among patients with SAP and an elevated TyG index.

CONCLUSIONS

The TyG index is a potential indicator for risk stratification and therapeutic decision-making in patients with TVD.