The Coronary Artery Revascularisation in Diabetes (CARDia) trial: background, aims, and design

Performance of the ACC/AHA Pooled Cohort Cardiovascular Risk Equations in Clinical Practice

BACKGROUND

The performance of the American College of Cardiology/American Heart Association pooled cohort equation (PCE) for atherosclerotic cardiovascular disease (ASCVD) in real-world clinical practice has not been evaluated extensively.

OBJECTIVES

The goal of this study was to test the performance of PCE to predict ASCVD risk in the community, and determine if including individuals with values outside the PCE range (ie, age, blood pressure, cholesterol) or statin therapy initiation over follow-up would significantly affect PCE predictive capabilities.

METHODS

The PCE was validated in a community-based cohort of consecutive patients who sought primary care in Olmsted County, Minnesota, between 1997 and 2000, followed-up through 2016. Inclusion criteria were similar to those of PCE derivation. Patient information was ascertained by using the record linkage system of the Rochester Epidemiology Project. ASCVD events (nonfatal and fatal myocardial infarction and ischemic stroke) were validated in duplicate. Calculated and observed ASCVD risk and c-statistics were compared across predefined groups.

RESULTS

This study included 30,042 adults, with a mean age of 48.5 ± 12.2 years; 46% were male. Median follow-up was 16.5 years, truncated at 10 years for this analysis. Mean ASCVD risk was 5.6% ± 8.73%. There were 1,555 ASCVD events (5.2%). The PCE revealed good performance overall (c-statistic 0.78) and in sex and race subgroups; it was highest among non-White female subjects (c-statistic 0.81) and lowest in White male subjects (c-statistic 0.77). Out-of-range values and initiation of statin medication did not affect model performance.

CONCLUSIONS

The PCE performed well in a community cohort representing real-world clinical practice. Values outside PCE ranges and initiation of statin medication did not affect performance. These results have implications for the applicability of current strategies for the prevention of ASCVD.

Systematic Review of Therapies for Stable Coronary Artery Disease in Diabetic Patients

Diabetes mellitus is a significant risk modifier for stable coronary artery disease, causing patients to have more extensive and diffuse lesions. Opposing treatment strategies remain a matter of debate. A multiple database search was conducted and outcomes, lesion, and patient characteristics were compared. Overall mortality, cardiac death, major adverse cardiovascular and cerebrovascular events, and need for revascularization were higher with percutaneous coronary intervention than with coronary artery bypass graft surgery. Multivessel disease and high Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) scores were associated with better outcomes for coronary artery bypass graft surgery.

Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis

OBJECTIVE

To investigate whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease.

DESIGN

Bayesian network meta-analyses to combine direct within trial comparisons between treatments with indirect evidence from other trials while maintaining randomisation.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

A strategy of initial medical treatment compared with revascularisation by coronary artery bypass grafting or Food and Drug Administration approved techniques for percutaneous revascularization: balloon angioplasty, bare metal stent, early generation paclitaxel eluting stent, sirolimus eluting stent, and zotarolimus eluting (Endeavor) stent, and new generation everolimus eluting stent, and zotarolimus eluting (Resolute) stent among patients with stable coronary artery disease.

DATA SOURCES

Medline and Embase from 1980 to 2013 for randomised trials comparing medical treatment with revascularisation.

MAIN OUTCOME MEASURE

All cause mortality.

RESULTS

100 trials in 93,553 patients with 262,090 patient years of follow-up were included. Coronary artery bypass grafting was associated with a survival benefit (rate ratio 0.80, 95% credibility interval 0.70 to 0.91) compared with medical treatment. New generation drug eluting stents (everolimus: 0.75, 0.59 to 0.96; zotarolimus (Resolute): 0.65, 0.42 to 1.00) but not balloon angioplasty (0.85, 0.68 to 1.04), bare metal stents (0.92, 0.79 to 1.05), or early generation drug eluting stents (paclitaxel: 0.92, 0.75 to 1.12; sirolimus: 0.91, 0.75 to 1.10; zotarolimus (Endeavor): 0.88, 0.69 to 1.10) were associated with improved survival compared with medical treatment. Coronary artery bypass grafting reduced the risk of myocardial infarction compared with medical treatment (0.79, 0.63 to 0.99), and everolimus eluting stents showed a trend towards a reduced risk of myocardial infarction (0.75, 0.55 to 1.01). The risk of subsequent revascularisation was noticeably reduced by coronary artery bypass grafting (0.16, 0.13 to 0.20) followed by new generation drug eluting stents (zotarolimus (Resolute): 0.26, 0.17 to 0.40; everolimus: 0.27, 0.21 to 0.35), early generation drug eluting stents (zotarolimus (Endeavor): 0.37, 0.28 to 0.50; sirolimus: 0.29, 0.24 to 0.36; paclitaxel: 0.44, 0.35 to 0.54), and bare metal stents (0.69, 0.59 to 0.81) compared with medical treatment.

CONCLUSION

Among patients with stable coronary artery disease, coronary artery bypass grafting reduces the risk of death, myocardial infarction, and subsequent revascularisation compared with medical treatment. All stent based coronary revascularisation technologies reduce the need for revascularisation to a variable degree. Our results provide evidence for improved survival with new generation drug eluting stents but no other percutaneous revascularisation technology compared with medical treatment.

Coronary artery bypass graft versus percutaneous coronary intervention with drug-eluting stent implantation for diabetic patients with unprotected left main coronary artery disease: the D-DELTA registry

AIMS

Data regarding the impact on clinical outcomes of PCI with DES implantation vs. CABG to treat unprotected left main coronary artery (ULMCA) disease in diabetic patients are still insufficient. The present study evaluated the short-term and long-term results of percutaneous and surgical revascularisation in diabetic patients with ULMCA disease in a large population.

METHODS AND RESULTS

A total of 826 diabetic patients with ULMCA stenosis who received DES (n=520) or underwent CABG (n=306) were selected and analysed from the DELTA registry. In-hospital MACCE was significantly higher in the CABG group, mainly driven by a higher incidence of MI. At four-year follow-up, freedom from death and the composite endpoint of death, MI and cerebrovascular accident (CVA) was similar in the two treatment groups (CABG 87.4%, PCI 82.5%, p=0.124, and CABG 85.4%, PCI 78.9%, p=0.11, respectively). Conversely, freedom from TVR and MACCE was significantly higher in the CABG compared to the PCI group (CABG 95.4%, PCI 79.4%, p<0.001, and CABG 81.9%, PCI 64.7%, p<0.001).

CONCLUSIONS

In diabetic patients with ULMCA disease with/without concomitant multivessel disease, PCI and CABG led to similar results in terms of death, MI and CVA. However, CABG was associated with less MACCE at long-term follow-up, primarily due to the higher repeat revascularisation rate with DES.

Can Minimally Invasive Coronary Artery Bypass Grafting be Initiated and Practiced Safely?

Objective

We examined the effects of learning curve on clinical outcomes and operative time in minimally invasive coronary artery bypass grafting (MICS CABG).

Methods

We studied 210 consecutive MICS CABG cases performed by the same surgeon, composed of 3 cardiopulmonary bypass (CPB)–assisted single-vessel small thoracotomy (SVST), 87 off-pump SVST, 51 CPB-assisted multivessel small thoracotomy (MVST), and 69 off-pump MVST. For each MICS CABG technique, the frequency of early clinical events (mortality, reopening, stroke, myocardial infarction, and revascularization) was compared between the first 25 cases and the remainder. Logarithmic curve regression analysis and a cumulative summation technique were performed to assess the correlation between operative time and the performed number of each technique.

Results

There was no mortality, and there were 10 conversions to standard sternotomy, all of which were intended as off-pump MVST ( P < 0.001, vs other procedures). Experience was otherwise not associated with perioperative outcome. However, experience numbers correlated with operative time in off-pump SVST and off-pump MVST (122 ± 30 minutes, R2 = 0.18, P < 0.001, and 241 ± 80 minutes, R2 = 0.38, P < 0.001, respectively) but not in CPB-assisted MVST (258 ± 44 minutes, R2 = 0.004, P = 0.7). No complications occurred as a result of CPB assistance.

Conclusions

Minimally invasive coronary artery bypass grafting can be safely initiated, with a very low perioperative risk. Pump assistance is a good strategy to alleviate some of the learning curve and avoid conversions to sternotomy when initiating a multivessel MICS CABG program. 2009:83–94.

Clinical outcomes with Biolimus (A9)™ eluting stent, 'BioMatrix' in diabetic patients--interim results from multicenter post market surveillance registry in India

OBJECTIVE

The objective of this registry is to establish safety and efficacy of BioMatrix, BioMatrix™-Biolimus A9™ eluting stent in diabetic population in India.

BACKGROUND

Diabetes mellitus is a major predisposing factor for coronary artery disease. Prognosis for diabetic population patients presenting with coronary artery disease who undergo coronary revascularization is inferior to non diabetics and remains an independent risk factor of restenosis, need for revascularization, and overall mortality. Stent thrombosis is a potential complication of first generation, permanent polymer drug-eluting stents. Biodegradable polymer is a good relief in this era and its utility in diabetic patients will be a major advantage for them.

METHODS

334 patients with diabetes mellitus and requiring angioplasty, implanted with BioMatrix stent were followed at 1, 6, 12 and 24 months who entered in a multicenter registry in India. We analyzed the incidence of major adverse cardiac events (MACE) and stent thrombosis (ST) at 1, 6, 12 and 24 months.

RESULTS

The mean age was 58.71 ± 9.2 years, 81% were males, comorbidity index was 1.6 ± 1.02, and 59.1% presented with acute coronary syndrome. The incidence of adverse event rates was: MACE 1.27%. There were no incidences of myocardial infarction (MI) and target vessel revascularization (TVR). Definite stent thrombosis occurred only in 2 patients.

CONCLUSION

In this registry of diabetic population treated with BioMatrixTM-Biolimus A9TM eluting stent (BioMatrix), the reported incidence of MACE and ST were much lower than previously published results. The 1- and 2-year follow-up result supports favorable clinical outcomes of using BioMatrix stents as a suitable alternative to contemporary DES available during PCI in diabetic patients.

Medical management and strategies to prevent coronary artery disease in patients with type 2 diabetes mellitus

Coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM) is associated with increased immediate and long-term mortality compared with patients without T2DM. The amplified incidence of CAD stems partly from the aggregation of multiple risk factors, such as obesity, dyslipidemia, and hypertension, which occur in this population. In addition, there appear to be increased forces at play at the molecular and vascular levels in these individuals, which is evidenced by the increased thrombosis and inflammation that is seen in those with diabetic atherosclerosis. Hence, there is a growing need to emphasize early and vigilant risk factor management in patients with T2DM to help reduce their burden of cardiovascular-related mortality. In this article, we review the primary and secondary prevention measures as well as the management of CAD in patients with T2DM.

Five-year outcomes of surgical or percutaneous myocardial revascularization in diabetic patients

BACKGROUND

The study compares five-year clinical outcomes of CABG vs PCI in a real world population of diabetic patients with multivessel coronary disease since it is not clear whether to prefer surgical or percutaneous revascularization.

METHODS

Between July 2002 and December 2008, 2885 multivessel coronary diabetic patients underwent revascularization (1466 CABG and 1419 PCI) at hospitals in Emilia-Romagna Region, Italy and were followed for 1827 ± 617 days by record linkage of two clinical registries with the regional administrative database of hospital admissions and the mortality registry. Five-year incidences of MACCE (mortality, acute myocardial infarction [AMI], stroke, and repeat revascularization [TVR]) were assessed with Kaplan-Meier estimates, Cox proportional hazards regression and cumulative incidence functions of death and TVR, to evaluate the competing risk of AMI on death and TVR. The same analyses were applied to the propensity score matched subgroup of patients undergoing CABG or PCI with DES and with complete revascularization.

RESULTS

PCI had higher mortality for all causes (HR: 1.8, 95% CI 1.4-2.2 p<0.0001), AMI (HR: 3.3, 95% CI 2.4-4.6 p<0.0001) and TVR (HR: 4.5, 95% CI 3.4-6.1 p<0.0001). No significant differences emerged for stroke (HR: 0.8, 95% CI 0.5-1.2 p=0.26). The higher incidence of AMI caused higher mortality in PCI group. Results did not change comparing CABG with PCI patients receiving complete revascularization or DES only.

CONCLUSIONS

Diabetics show a higher incidence of MACCE with PCI than with CABG: thus diabetes and its degree of control should be considered when choosing the type of revascularization.

Myocardial function may improve equally in diabetic patients following both multivessel percutaneous coronary intervention and coronary artery bypass grafting: results from a CARDia trial substudy

AIMS

The CARDia (Coronary Artery Revascularization in Diabetes) trial compared coronary artery bypass grafting (CABG) and optimal percutaneous coronary intervention (PCI) in diabetic patients with multivessel coronary disease. Patients enrolled had symptoms of myocardial ischaemia. As symptom assessment is flawed in diabetic patients, a substudy was undertaken to compare the extent to which these revascularization strategies alter reversible ischaemia.

METHODS AND RESULTS

Seventy-one patients underwent stress echo at baseline and at 6 months. A 17-segment echocardiographic wall motion score index (WMSI) was assigned at baseline [WMSI(pre)] and at 6 months [WMSI(post)]. An overall score defined the difference: WMSI(∂) = WMSI(pre)--WMSI(post). Of 71 patients recruited, 42 underwent PCI and 29 CABG. Mean WMSI(pre) in the PCI group was 1.63 and mean WMSI(post) was 1.32. Mean WMSI(pre) in the CABG group was 1.69 and mean WMSI(post) was 1.46. The PCI WMSI(∂) was 0.31 and CABG WMSI(∂) was 0.23 (P = 0.8). Of 42 PCI patients, 39 demonstrated ischaemia at baseline. At 6 months 31 had improvements in ischaemia (79%), 5 showed no improvement, and 3 ischaemia worsened. Of 29 CABG patients, 23 demonstrated ischaemia at baseline. At 6 months, 20 had improvements in ischaemia (87%), 2 had no improvement, and in 1 ischaemia worsened. No difference was seen in the number of patients with improvements in reversible ischaemia between PCI and CABG [79 vs. 87%, (P = 0.9)].

CONCLUSION

Optimal revascularization in diabetic patients with multivessel disease remains controversial. This subset analysis of the CARDia trial suggests both PCI and CABG achieve similar improvement in reversible ischaemia.

5-Year follow-up of coronary revascularization in diabetic patients with multivessel coronary artery disease: insights from ARTS (arterial revascularization therapy study)-II and ARTS-I trials

OBJECTIVES

We compared the 5-year outcomes of diabetic patients with multivessel disease treated with sirolimus-eluting stents (SES), bare-metal stents (BMS), and coronary artery bypass graft surgery (CABG) enrolled in the ARTS (Arterial Revascularization Therapy Study) I and II studies.

BACKGROUND

Diabetes is an established risk factor for major adverse cardiac events after revascularization. Recent trials suggest that revascularization with drug-eluting stents has equivalent safety to CABG up to 2 years.

METHODS

The ARTS I and II studies included 367 diabetic patients (SES: 159, CABG: 96, and BMS: 112) compared with respect to 5-year clinical outcomes.

RESULTS

The rate of major adverse cardiovascular and cerebrovascular events was significantly higher in patients treated with BMS (BMS 53.6% vs. CABG 23.4% vs. SES 40.5%; log-rank, p < 0.01 for SES vs. BMS and SES vs. CABG). There was no significant difference in mortality among all 3 groups. There was, however, a statistically significant difference in the myocardial infarction rate between BMS and CABG arms (BMS 11.0%, CABG 5.2%, SES 4.8%, p = 0.04 for SES vs. BMS and p = 0.76 for SES vs. CABG). The rate of repeat revascularization was significantly lower in patients treated with CABG compared with SES (SES 33.2% vs. CABG 10.7%, p < 0.001). Revascularization rate of patients treated with SES at 5 years approached that of patients treated with BMS although remained significantly lower. This "catch-up" phenomenon was not apparent in the nondiabetic population.

CONCLUSIONS

At 5-year follow-up, CABG has comparable safety and superior efficacy compared with BMS and SES in the treatment of diabetic patients with multivessel disease.

Three-vessel coronary disease in diabetics: personalized versus evidence-based revascularization strategy

A steady increase in the number of diabetic patients undergoing coronary revascularization has been recorded in recent years. The causes for this rise are found predominantly in the general demographic development of western industrialized nations, the epidemic progress and wide-spread of diabetes mellitus and changes in assignment behavior. In this article, the specific risk profile of diabetic coronary patients with three-vessel disease in percutaneous or surgical revascularization and tried and tested treatment concepts for this particularly challenging group of patients, with reference to the most recent study results will be presented. Particularly, the peculiarities of coronary heart disease in diabetic patients, the choice of revascularization method, different operative strategies for diabetic patients with coronary heart disease, and challenges faced during follow-up are discussed.

Marital Status, Hypertension, Coronary Heart Disease, Diabetes, and Death Among African American Women and Men: Incidence and Prevalence in the Atherosclerosis Risk in Communities (ARIC) Study Participants

Heart disease is the leading cause of death in the United States, and African Americans disproportionately experience more cardiovascular disease, including coronary heart disease (CHD), hypertension, and diabetes. The literature documents a complex relationship between marital status and health, which varies by gender. We prospectively examine the relationship between African American men’s and women’s marital status and their risk of developing cardiovascular diseases and dying using the Atherosclerosis Risk in Communities (ARIC) data. After multivariable adjustment for individual characteristics and health status, we found that marital status was not associated with hypertension or new cases of CHD, but remaining single throughout the study period was associated with an increased risk of developing diabetes for women and an increased likelihood of death for men. Culturally appropriate interventions for African Americans are needed to decrease racial disparities in cardiovascular diseases and mortality.

Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial

OBJECTIVES

The purpose of this study was to compare the safety and efficacy of percutaneous coronary intervention (PCI) with stenting against coronary artery bypass grafting (CABG) in patients with diabetes and symptomatic multivessel coronary artery disease.

BACKGROUND

CABG is the established method of revascularization in patients with diabetes and multivessel coronary disease, but with advances in PCI, there is uncertainty whether CABG remains the preferred method of revascularization.

METHODS

The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), and stroke, and the main secondary outcome included the addition of repeat revascularization to the primary outcome events. A total of 510 diabetic patients with multivessel or complex single-vessel coronary disease from 24 centers were randomized to PCI plus stenting (and routine abciximab) or CABG. The primary comparison used a noninferiority method with the upper boundary of the 95% confidence interval (CI) not to exceed 1.3 to declare PCI noninferior. Bare-metal stents were used initially, but a switch to Cypher (sirolimus drug-eluting) stents (Cordis, Johnson & Johnson, Bridgewater, New Jersey) was made when these became available.

RESULTS

At 1 year of follow-up, the composite rate of death, MI, and stroke was 10.5% in the CABG group and 13.0% in the PCI group (hazard ratio [HR]: 1.25, 95% CI: 0.75 to 2.09; p=0.39), all-cause mortality rates were 3.2% and 3.2%, and the rates of death, MI, stroke, or repeat revascularization were 11.3% and 19.3% (HR: 1.77, 95% CI: 1.11 to 2.82; p=0.02), respectively. When the patients who underwent CABG were compared with the subset of patients who received drug-eluting stents (69% of patients), the primary outcome rates were 12.4% and 11.6% (HR: 0.93, 95% CI: 0.51 to 1.71; p=0.82), respectively.

CONCLUSIONS

The CARDia (Coronary Artery Revascularization in Diabetes) trial is the first randomized trial of coronary revascularization in diabetic patients, but the 1-year results did not show that PCI is noninferior to CABG. However, the CARDia trial did show that multivessel PCI is feasible in patients with diabetes, but longer-term follow-up and data from other trials will be needed to provide a more precise comparison of the efficacy of these 2 revascularization strategies. (The Coronary Artery Revascularisation in Diabetes trial; ISRCTN19872154).

The role of revascularization versus medical therapy in patients with type 2 diabetes mellitus and coronary artery disease

Patients with type 2 diabetes mellitus (T2DM) are at increased risk for cardiovascular clinical events, adverse nonfatal outcomes, and death. There has been considerable improvement in the medical management of patients with T2DM in an attempt to alter the metabolic cascade that is triggered by insulin resistance. Recent trials have demonstrated that medical management of patients with diabetes mellitus and stable coronary artery disease (CAD) is equivalent to revascularization in terms of morality benefit and rates of major adverse cardiovascular events, particularly in patients who do not have extensive CAD. Nonetheless, in those diabetic patients with additional high-risk features including left main disease, reduced left ventricular ejection fraction (LVEF), severe ischemia, or acute coronary syndrome, revascularization remains the best treatment option. Although the evidence still supports coronary artery bypass grafting (CABG) as the standard of care for revascularization of diabetic patients with multivessel CAD and/or reduced LVEF, percutaneous coronary intervention (PCI) with drug-eluting stents (DES) has resulted in at least partial closure of the gap in benefit between surgery and catheter-based intervention. Ongoing trials of diabetic patients with CAD randomized to PCI or CABG will help further elucidate the role of PCI with DES as a potential revascularization option for this patient population.

Comparison of medium-term outcomes obtained with drug-eluting stents and coronary artery bypass grafts in an unselected population of diabetic patients with multivessel coronary disease. Propensity score analysis

INTRODUCTION AND OBJECTIVES

Since the introduction of drug-eluting stents, the optimum revascularization strategy in diabetic patients with multivessel coronary disease has remained controversial.

METHODS

This study used multivariate logistic regression analysis and propensity score matching to compare results in 270 consecutive diabetic patients (2000-2004) with multivessel disease (> or =2 vessels with a >70% de novo stenosis involving the proximal left anterior descending coronary artery) who underwent either coronary artery bypass grafting (CABG; n=142) or implantation of a drug-eluting stent (DES; i.e. rapamycin or paclitaxel; n=128). The following clinical outcomes (i.e. major adverse cardiac or cerebrovascular events [MACCEs]) were assessed: death, nonfatal myocardial infarction (MI), stroke and repeat revascularization at 2 years.

RESULTS

Patients who received DESs were older (67.5+/-7 years vs. 65.3+/-8 years; P=.05) and more often had a previous MI (49.2% vs. 28.2%; P< .01), but no more often had a depressed left ventricular ejection fraction < or =45% (32.4% vs. 28.1%). Coronary anatomy was more complex in surgical patients (SYNTAX score, 25.9+/-7 vs. 18.5+/-6; P< .001) and the quality of revascularization was better (i.e. anatomically complete revascularization: 52.8% vs. 28.1%; P< .01). The incidence of MACCEs was 18.7% in the CABG group and 21.8% in the DES group (adjusted odds ratio [OR] = 0.93; 95% confidence interval [CI], 0.47-1.86). The composite endpoint of death, MI or stroke occurred in 15.8% undergoing CABG and 12.9% receiving a DES (adjusted OR = 1.19; 95% CI, 0.72-1.88). There was less need for revascularization in CABG patients (4.3% vs. 12.1%; adjusted OR = 0.42; 95% CI, 0.16-1.14; P=.09).

CONCLUSIONS

In an unselected population of diabetic patients with multivessel coronary disease, the principle advantage of CABG was the reduced need for revascularization. There was no difference in the rate of death, MI or stroke.

Diabetes mellitus: a prothrombotic state implications for outcomes after coronary revascularization

Coronary stent thrombosis is a serious problem in the drug-eluting stent era. Despite aggressive antiplatelet therapy during and after percutaneous coronary intervention (PCI), the incidence of sub-acute stent thrombosis remains approximately 0.5%–2%, which may represent a catastrophic clinical situation. Both procedural factors and discontinuation of antiplatelet therapy are normally associated with this event. We report on simultaneous stent thromboses of two drug-eluting stents implanted in two different vessels, which resulted in a life-threatening clinical condition. Possible contributing factors that led to synergistic thrombotic effects are discussed.

Comparison of drug-eluting stents and coronary artery bypass surgery for the treatment of multivessel coronary disease: three-year follow-up results from a single institution

BACKGROUND

Numerous studies have compared the outcomes of coronary artery bypass grafting (CABG) surgery and coronary stenting for the treatment of multivessel coronary disease. In 2003, drug-eluting stents were introduced with the hope of reducing restenosis. However, limited information exists on the comparison of drug-eluting stents and CABG surgery. The long-term outcome of drug-eluting stents compared with that of CABG surgery is also unclear.

METHODS AND RESULTS

We identified 3720 consecutive patients with multivessel disease who underwent isolated CABG surgery or received drug-eluting stents between April 1, 2004, and December 31, 2005, and we compared safety (total mortality, myocardial infarction, and stroke) and efficacy (target-vessel revascularization) during a 3-year follow-up. These outcomes were compared after adjustment for differences in baseline risk factors. Patients who underwent CABG (n=1886) were older and had more comorbidities than patients who received drug-eluting stents (n=1834). Patients receiving drug-eluting stents had considerably higher 3-year rates of target-vessel revascularization. Drug-eluting stents were also associated with higher rates of death (adjusted hazard ratio, 1.62; 95% confidence interval, 1.07 to 2.47) and myocardial infarction (adjusted hazard ratio, 1.65; 95% confidence interval, 1.15 to 2.44). The risk adjusted rate of stroke was similar in the 2 groups (hazard ratio, 0.92; 95% confidence interval, 0.69 to 1.51).

CONCLUSIONS

In a cohort of patients with multivessel disease, CABG was associated with lower rates of death, myocardial infarction, and target-vessel revascularization than drug-eluting stents.

Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials

BACKGROUND

Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are alternative treatments for multivessel coronary disease. Although the procedures have been compared in several randomised trials, their long-term effects on mortality in key clinical subgroups are uncertain. We undertook a collaborative analysis of data from randomised trials to assess whether the effects of the procedures on mortality are modified by patient characteristics.

METHODS

We pooled individual patient data from ten randomised trials to compare the effectiveness of CABG with PCI according to patients' baseline clinical characteristics. We used stratified, random effects Cox proportional hazards models to test the effect on all-cause mortality of randomised treatment assignment and its interaction with clinical characteristics. All analyses were by intention to treat.

FINDINGS

Ten participating trials provided data on 7812 patients. PCI was done with balloon angioplasty in six trials and with bare-metal stents in four trials. Over a median follow-up of 5.9 years (IQR 5.0-10.0), 575 (15%) of 3889 patients assigned to CABG died compared with 628 (16%) of 3923 patients assigned to PCI (hazard ratio [HR] 0.91, 95% CI 0.82-1.02; p=0.12). In patients with diabetes (CABG, n=615; PCI, n=618), mortality was substantially lower in the CABG group than in the PCI group (HR 0.70, 0.56-0.87); however, mortality was similar between groups in patients without diabetes (HR 0.98, 0.86-1.12; p=0.014 for interaction). Patient age modified the effect of treatment on mortality, with hazard ratios of 1.25 (0.94-1.66) in patients younger than 55 years, 0.90 (0.75-1.09) in patients aged 55-64 years, and 0.82 (0.70-0.97) in patients 65 years and older (p=0.002 for interaction). Treatment effect was not modified by the number of diseased vessels or other baseline characteristics.

INTERPRETATION

Long-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes. CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups.

Three-year survival following multivessel percutaneous coronary intervention with bare-metal or drug-eluting stents in unselected patients

Drug-eluting stents (DESs) have been shown to reduce the rate of repeat revascularization compared with bare-metal stents (BMSs) after multivessel percutaneous coronary intervention in carefully selected patients. However, the long-term safety and efficacy of DESs in patients with multivessel disease outside the setting of randomized trials was unknown. Therefore, all patients undergoing multivessel percutaneous coronary intervention with BMSs, sirolimus-eluting stents (SESs), or paclitaxel-eluting stents (PESs) from January 2000 to December 2005 were investigated. The primary end point was all-cause mortality. A total of 1,720 patients were recruited in 3 consecutive sequential groups of BMS (n=701; January 2000 to April 2002), SES (n=293; April 2002 to February 2003), and PES (n=726; February 2003 to December 2005). Overall median follow-up was 1,440 days. There was improved 3-year survival in the SES group (93.7%) compared with both the BMS (86.1%) and PES groups (87.3%), which remained significant after propensity score adjustment for differences in baseline and procedural characteristics (SES vs BMS, adjusted hazard ratio 0.53, 95% confidence interval 0.30 to 0.94; SES vs PES, adjusted hazard ratio 0.49, 95% confidence interval 0.28 to 0.87). There was no difference in mortality between the PES and BMS groups. Both DES types significantly reduced the need for clinically driven target-vessel and target-lesion revascularization without an excess in myocardial infarction or stent thrombosis. In conclusion, both SESs and PESs significantly reduced the need for repeated revascularization in these patients with no excess in mortality. SESs might reduce mortality in patients undergoing multivessel percutaneous coronary intervention.

Optimal revascularization strategy for diabetic patients with multivessel coronary artery disease: the duel between old hero and young warrior

Given the results of the BARI and ARTS I trials and a meta-analysis, coronary artery bypass surgery has been preferred to percutaneous coronary intervention in diabetics with multivessel coronary artery disease requiring hypoglycemic treatment and in whom internal mammary artery grafts can be used. This approach was strongly recommended in a 2002 ACC/AHA Task Force on the management of patients with acute coronary syndrome. But, these recommendations were made before the availability of drug-eluting stents. We strongly believe that the ongoing, multi-centre FREEDOM, CARDia and SYNTAX trials will elucidate the optimal revascularization strategy for diabetic patients with multivessel disease in the near future.

Drug-Eluting or Bare-Metal Stenting in Patients With Diabetes Mellitus

Background— Patients with diabetes mellitus (DM) are at high risk for restenosis, myocardial infarction, and cardiac mortality after coronary stenting, and the long-term safety of drug-eluting stents (DES) relative to bare-metal stents (BMS) in DM is uncertain. We report on a large consecutive series of patients with DM followed up for 3 years after DES and BMS from a regional contemporary US practice with mandatory reporting.

Methods and Results— All adults with DM undergoing percutaneous coronary intervention with stenting between April 1, 2003, and September 30, 2004, at all acute care nonfederal hospitals in Massachusetts were identified from a mandatory state database. According to index admission stent type, patients were classified as DES treated if all stents were drug eluting and as BMS treated if all stents were bare metal; patients treated with both types of stents were excluded from the primary analysis. Mortality rates were obtained from vital statistics records, and myocardial infarction and revascularization rates were obtained from the state database with complete 3 years of follow-up on the entire cohort. Risk-adjusted mortality, myocardial infarction, and revascularization differences (DES−BMS) were estimated with propensity-score matching based on clinical, procedural, hospital, and insurance information collected at the index admission. DM was present in 5051 patients (29% of the population) treated with DES or BMS during the study. Patients with DM were more likely to receive DES than BMS (66.1% versus 33.9%; P <0.001). The unadjusted cumulative incidence of mortality at 3 years was 14.4% in DES versus 22.2% in BMS ( P <0.001). Based on propensity-score analysis of 1:1 matched DES versus BMS patients (1476 DES:1476 BMS), the risk-adjusted mortality, MI, and target vessel revascularization rates at 3 years were 17.5% versus 20.7% (risk difference, −3.2%; 95% confidence interval, −6.0 to −0.4; P =0.02), 13.8% versus 16.9% (−3.0%; 95% confidence interval, −5.6 to 0.5; P =0.02), and 18.4% versus 23.7% (−5.4%; confidence interval, −8.3 to −2.4; P <0.001), respectively.

Conclusions— In a real-world diabetic patient population with mandatory reporting and follow-up, DES were associated with reduced mortality, myocardial infarction, and revascularization rates at long-term follow-up compared with BMS.

Optimal treatment of the diabetic patient with multivessel disease

Diabetes is emerging as a major source of cardiovascular morbidity and mortality. The atherosclerosis associated with diabetes has a complex etiology with even more complicated manifestations, such as multivessel and diffuse coronary disease. The optimal management of the diabetic patient with multivessel disease poses a special challenge in terms of the selection of the revascularization strategy and medical therapies. In this article, we assess the evidence accumulated to date and discuss ongoing studies that will help better inform this intricate decision-making process.

The impact of diabetic status on coronary artery bypass graft patency: insights from the radial artery patency study

BACKGROUND

Despite worse outcomes in diabetics after coronary artery bypass grafting surgery, studies have not examined graft patency in this high-risk group. This study examined the impact of diabetes on graft patency, 1-year postcoronary artery bypass grafting, using data from a multicenter randomized trial.

METHODS AND RESULTS

The Radial Artery Patency Study enrolled 561 patients undergoing coronary artery bypass grafting, comparing graft patency of the saphenous vein (SV) versus radial artery 1-year postcoronary artery bypass grafting. Angiographic follow-up was acquired for 440 patients (115 diabetics, 325 nondiabetics), each with a study radial artery and a control SV graft. Preoperative characteristics were similar. The proportion of small-sized target vessels was greater in diabetics (P=0.04). At 1 year, 33 of 230 study grafts (14.4%) were occluded in the diabetics versus 63 of 650 (9.7%) in the nondiabetics (P=0.052). Multivariable regression found diabetes to be a significant independent predictor of 1-year graft occlusion (relative risk, 1.45; 95% CI, 1.03 to 2.05; P=0.03) along with female gender, SV conduit, and small target-vessel size. A significantly higher proportion of SV grafts were occluded in the diabetics (19% versus 12%, P=0.04). Radial artery grafting was protective in the diabetic cohort (radial artery: 11 of 115 occluded [9.5%] versus SV: 22 of 115 occluded [19.1%], McNemar corrected P=0.05; relative risk, 0.42; 95% CI, 0.16 to 1.01) and nondiabetics (radial artery: 25 of 325 occluded [7.7%] versus SV: 38 of 325 occluded [11.7%], McNemar corrected P=0.11; relative risk, 0.63; 95% CI, 0.35 to 1.10).

CONCLUSIONS

Coronary artery bypass grafting occlusions were more common among diabetics versus nondiabetics at 1-year angiography, mainly because of more frequent SV graft failure in diabetics. Radial artery, compared with SV grafting, is protective in both diabetic and nondiabetic patients.

Baseline characteristics of patients with diabetes and coronary artery disease enrolled in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial

BACKGROUND

The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial was undertaken to determine whether early revascularization intervention is superior to deferred intervention in the presence of aggressive medical therapy and whether antidiabetes regimens targeting insulin sensitivity are more or less effective than regimens targeting insulin provision in reducing cardiovascular events among patients with type 2 diabetes mellitus and stable coronary artery disease (CAD).

METHODS

The BARI 2D trial is a National Institutes of Health-sponsored randomized clinical trial with a 2 x 2 factorial design. Between 2001 and 2005, 49 clinical sites in North America, South America, and Europe randomized 2,368 patients. At baseline, the trial collected data on clinical history, symptoms, and medications along with centralized evaluations of angiograms, electrocardiograms, and blood and urine specimens.

RESULTS

Most of the BARI 2D patients were referred from the cardiac catheterization laboratory (54%) or cardiology clinic (27%). Of the randomized participants, 30% were women, 34% were minorities, 61% had angina, and 67% had multiregion CAD. Moreover, 29% had been treated with insulin, 58% had hemoglobin A(1c) >7.0%, 41% had low-density lipoprotein cholesterol >or=100 mg/dL, 52% had blood pressure >130/80 mm Hg, and 56% had body mass index >or=30 kg/m(2).

CONCLUSIONS

Baseline characteristics in BARI 2D are well balanced between the randomized treatment groups, and the clinical profile of the study cohort is representative of the target population. As a result, the BARI 2D clinical trial is in an excellent position to evaluate alternative treatment approaches for diabetes and CAD.

Randomized, controlled trial of coronary artery bypass surgery versus percutaneous coronary intervention in patients with multivessel coronary artery disease: six-year follow-up from the Stent or Surgery Trial (SoS)

BACKGROUND

The Stent or Surgery Trial is a randomized, controlled trial comparing percutaneous coronary intervention with coronary artery bypass grafting (CABG) for patients with multivessel disease. Initial results at a median follow-up of 2 years showed a survival advantage for patients randomized to CABG. This article reports survival outcome at a median follow-up of 6 years.

METHODS AND RESULTS

A total of 988 (n=488 percutaneous coronary intervention, n=500 CABG) patients were randomized at 53 centers during the period from 1996 to 1999. Investigators established survival status from hospital or community medical records or national databases or by direct contact with patients and their relatives. All-cause mortality was compared with hazard ratios and confidence intervals calculated from Cox proportional hazards models. Prespecified subgroup analyses for diabetes mellitus, angina grade, and angiographic severity of coronary disease at baseline were performed with tests for interaction. At a median follow-up of 6 years, 53 patients (10.9%) died in the percutaneous coronary intervention group compared with 34 (6.8%) in the CABG group (hazard ratio 1.66, 95% confidence interval 1.08 to 2.55, P=0.022). Little evidence was found that the treatment effect on mortality differed between subgroups according to baseline angina grade (interaction test P=0.52), the severity of coronary disease (P=0.92), or diabetic status (P=0.15).

CONCLUSIONS

At a median follow-up of 6 years, a continuing survival advantage was observed for patients managed with CABG, which is not consistent with results from other stent-versus-CABG studies.

Multivessel disease: percutaneous coronary intervention for classic coronary artery bypass grafting indications

Multivessel coronary artery disease is characterized by involvement of greater than 1 epicardial coronary artery or the unprotected left main. The choice of revascularization strategy in this setting remains a critical issue in cardiology. Although coronary artery bypass grafting has traditionally been the revascularization strategy for most patients with multivessel disease, there has been a gradual shift toward percutaneous revascularization. Early randomized clinical trials showed coronary artery bypass grafting to be superior to medical therapy. However, trials comparing coronary artery bypass grafting to bare metal stenting have not shown a mortality benefit. Advancements in interventional techniques will continue to challenge the notion that coronary artery bypass grafting is the standard therapy for patients with multivessel coronary disease. Several ongoing randomized clinical trials comparing coronary artery bypass grafting to drug-eluting stents will provide valuable insight into the role of each procedure. In this article, we review the existing literature and discuss future directions in the management of the patient with multivessel disease.

Long-Term Mortality After Percutaneous Coronary Intervention With Drug-Eluting Stent Implantation Versus Coronary Artery Bypass Surgery for the Treatment of Multivessel Coronary Artery Disease

Background— Although previous studies have compared the treatment effects of percutaneous coronary intervention and coronary artery bypass grafting (CABG), the long-term outcomes beyond 1 year among patients with multivessel coronary artery disease who underwent percutaneous coronary intervention with drug-eluting stents (DES) or CABG have not been evaluated.

Methods and Results— Between January 2003 and December 2005, 3042 patients with multivessel disease underwent coronary implantation of DES (n=1547) or CABG (n=1495). The primary end point was all-cause mortality. In a crude analysis, the rate of long-term mortality was significantly higher in patients who underwent CABG than in those who underwent DES implantation (3-year unadjusted mortality rate, 7.0% for CABG versus 4.4% for percutaneous coronary intervention; P =0.01). However, after adjustment for baseline differences, the overall risks of death were similar among all patients (hazard ratio, 0.85; 95% confidence interval [CI], 0.56 to 1.30; P =0.45), diabetic patients (hazard ratio, 1.76; 95% CI, 0.82 to 3.78; P =0.15), and patients with compromised ventricular function (hazard ratio, 1.39; 95% CI, 0.41 to 4.65; P =0.60). In the anatomic subgroups, mortality benefit with DES implantation was noted in patients with 2-vessel disease with involvement of the nonproximal left anterior descending artery (hazard ratio, 0.23; 95% CI, 0.01 to 0.78; P =0.016). The rate of revascularization was significantly higher in the DES than in the CABG group (hazard ratio, 2.81; 95% CI, 2.11 to 3.75; P <0.001).

Conclusions— For the treatment of multivessel coronary artery disease, percutaneous coronary intervention with DES implantation showed equivalent long-term mortality as CABG.

Secondary prevention of cardiovascular disease in type 2 diabetes and prediabetes: a cardiologist's perspective

Patients with type 2 diabetes mellitus (T2DM) and prediabetes have a substantially greater risk of developing cardiovascular (CV) disease than the general population. This increased risk of CV disease is due to a complex cluster of risk factors including insulin resistance, hyperglycaemia, diabetic dyslipidaemia, hypertension and systemic inflammation. As a result of this cluster of risk factors, life expectancy is reduced by up to 10 years upon diagnosis of T2DM, principally because of fatal CV events. Patients with T2DM are not only more likely to sustain a CV event, but also have a higher risk of a fatal outcome from this event. Therefore, whilst primary prevention is critical in determining the prognosis of patients newly diagnosed with T2DM, many will go on to suffer CV events and represent a high-risk group requiring intensive secondary prevention techniques. Recent data demonstrate that contemporary prevention therapies do not afford equal benefits to T2DM sufferers after acute myocardial infarction compared with their non-diabetic counterparts. This finding highlights the need for more effective secondary preventative strategies to prevent recurrent CV events in patients with T2DM and prediabetes. The cardiologist's role in the multidisciplinary management of T2DM is to improve patient outcomes by optimising use of evidence-based strategies for the prevention of recurrent CV events.

Diabetic endovascular disease: role of coronary artery revascularization

This century brings a pandemic of diabetes mellitus, with marked increases in early-accelerated atherosclerosis. When asymptomatic patients with diabetes present for evaluation, they have more extensive coronary atherosclerosis, lower ejection fractions, higher rates of previous cardiac events, and more silent ischemia than the normal population. The challenge faced by clinicians is to accurately identify asymptomatic patients with diabetes who have significant coronary ischemia that would benefit from revascularization. Diabetic endovascular disease has all the high-risk features to promote atherosclerosis and coronary occlusion: hyperglycemia-induced endothelial dysfunction, impaired fibrinolysis, increased platelet aggregation, plaque instability, dysfunctional arterial remodeling, and fibrotic and calcified coronary arteries. The optimal revascularization strategy for patients with diabetes is an ongoing debate. The advent of drug-eluting stents has changed the landscape, and some have suggested that the current role of coronary artery bypass grafting may be reduced by as much as 46%. Unfortunately, there is limited evidence from randomized, controlled trials that reflects current practice and could guide clinicians in making the best choices for patients with diabetes and coronary disease. It is hoped that ongoing trials--including Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D), Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM), and Coronary Artery Revascularisation in Diabetes (CARDia)--will answer many of the remaining questions. Still, the best treatment includes lifestyle modification and early prevention strategies with global risk reduction.

Coronary heart disease in patients with diabetes: part II: recent advances in coronary revascularization

Although diabetic patients represent approximately one-quarter of all those undergoing revascularization, their outcomes after revascularization are usually worse compared with non-diabetic patients. We examined the recent advances in percutaneous and surgical revascularization that are relevant to the treatment of diabetic patients. A systematic review of publications in the past 5 years (2000 to 2005) relating to coronary revascularization in diabetes was undertaken. Early and mid-term follow-up of diabetic patients after revascularization indicates that the incidence of myocardial infarction and repeat revascularization are reduced in surgically treated patients compared with those treated by balloon angioplasty alone. Percutaneous coronary intervention (PCI) with bare metal stents has reduced the surgical advantage (for reintervention) in the early-mid-term; however, repeat revascularization in diabetic patients continues to be substantially higher after PCI. Advances in PCI include the use of drug-eluting stents and adjunctive drug therapies, such as abciximab. Glycemic control is an important determinant of outcome after revascularization in diabetic patients, and the impact of tight glycemic control after PCI is currently being investigated in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 in Diabetes). Improvements in PCI and coronary artery bypass graft surgery are leading to better results in diabetic patients, and clinical trials are presently comparing contemporary PCI with surgery.

Progressive stent technologies: new approaches for the treatment of cardiovascular diseases

The CYPHER (Cordis, Johnson & Johnson) sirolimus-eluting stent and the TAXU (Boston Scientific) paclitaxel-eluting stent have been extensively evaluated and have been proven to be significant novel tools for the treatment of coronary artery disease. Several sirolimus derivatives have already emerged, receiving CE Mark approval. However, in the future, it is likely that drugs presently under investigation will address additional mechanisms associated with neointimal formation, either as single agents or in combination with antiproliferative compounds. Concurrently, alterations on stent platform design (helicoidal, open-closed cell), coatings (biodegradable, bioabsorbable, nanoporous) and polymers are being explored.

Three-year clinical follow-up of the unrestricted use of sirolimus-eluting stents as part of the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) registry

Sirolimus-eluting stents (SESs) have been shown to decrease restenosis compared with bare metal stents (BMSs). Currently, there are limited data on the long-term efficacy of these devices in a real-world patient population. Furthermore, the potential of a late restenotic phenomenon has not yet been excluded. From April to October 2002, 508 consecutive patients with de novo lesions exclusively treated with SESs were enrolled and compared with 450 patients treated with BMSs in the preceding 6 months (control group). Patients in the SES group more frequently had multivessel disease and type C lesions, received more stents, and had more bifurcation stenting. After 3 years, the cumulative incidence of major adverse cardiac events (comprising death, myocardial infarction, and target vessel revascularization) was significantly lower in the SES group compared with the pre-SES group (18.9% vs 24.7%, hazards ratio 0.73, 95% confidence interval 0.56 to 0.96, p = 0.026). The 3-year risk of target lesion revascularization was 7.5% in the SES group versus 12.6% in the pre-SES group (hazards ratio 0.57, 95% confidence interval 0.38 to 0.87, p = 0.01). In conclusion, the unrestricted use of SESs is safe and superior to the use of BMSs. The beneficial effects, reported after 1 and 2 years in reducing major adverse cardiac events, persisted with no evidence of a clinical late restenotic "catch-up" phenomenon.