Influence of diabetes mellitus on long-term (five-year) outcomes of drug-eluting stents and coronary artery bypass grafting for multivessel coronary revascularization

Type 2 diabetes mellitus and In-hospital Major Adverse Cardiac and Cerebrovascular Events (MACCEs) and postoperative complications among patients undergoing on-pump isolated coronary artery bypass surgery in Northeastern Iran

BACKGROUND

Diabetes Mellitus (DM) is a rapidly growing disorder worldwide, especially in the Middle East. A higher incidence of coronary artery diseases requiring coronary artery bypass graft (CABG) surgery has been reported in patients with diabetes. We assessed the association between type 2 diabetes mellitus (T2DM) and in-hospital major adverse cardiac and cerebrovascular events (MACCEs) and postoperative complications among patients who underwent on-pump isolated CABG.

METHODS

In this retrospective cohort study, we used the data registered for CABG patients from two heart centers in the Golestan province (North of Iran) between 2007 and 2016. The study population included 1956 patients divided into two groups: 1062 non-diabetic patients and 894 patients with diabetes (fasting plasma glucose ≥126 mg/dl or using antidiabetic medications). The study outcome was in-hospital MACCEs, a composite outcome of myocardial infarction (MI), stroke and cardiovascular death, and postoperative complications, including postoperative arrhythmia, acute atrial fibrillation (AF), major bleeding (defined as reoperation due to bleeding), and acute kidney injury (AKI).

RESULTS

During the 10-year study period, 1956 adult patients with a mean (SD) age of 59.0 (9.60) years were included. After adjustment for age, gender, ethnicity, obesity, opium consumption, and smoking, diabetes was a predictor of postoperative arrhythmia (AOR 1.30, 95% CI 1.08-1.57; P = 0.006). While it was not a predictor of in-hospital MACCEs (AOR 1.35, 95% CI 0.86, 2.11; P = 0.188), AF (AOR 0.85, 95% CI 0.60-1.19; P = 0.340), major bleeding (AOR 0.80, 95% CI 0.50, 1.30; P = 0.636) or AKI (AOR 1.29, 95% CI 0.42, 3.96; P 0.656) after CABG surgery.

CONCLUSION

Findings indicated that diabetes increased the risk of postoperative arrhythmia by 30%. However, we found similar in-hospital MACCEs, acute AF, major bleeding, and AKI following CABG surgery in both diabetic and non-diabetic patients.

Secondary prevention after CABG: do new agents change the paradigm?

PURPOSE OF REVIEW

Coronary artery bypass graft (CABG) surgery remains the gold-standard treatment for multivessel and left main coronary artery disease. Despite significant improvement in cardiovascular outcomes, patients undergoing CABG remain at risk for recurrent adverse ischemic events and other cardiovascular outcomes (coronary revascularisation, stroke, cardiac death, etc.). The purpose of this review is to summarize the most recent evidence in pharmacological preventive therapies addressing the residual cardiovascular risk in patients who have undergone CABG.

RECENT FINDINGS

Novel cardiovascular pharmacological preventive strategies targeting inflammatory, metabolic and prothrombotic (antiplatelet and anticoagulation) pathways have been recently assessed, with promising results for secondary prevention after CABG.

SUMMARY

Secondary prevention is an essential part of postoperative care after CABG. Novel lipid-lowering and glucose-controlling agents suggest a strong and consistent benefit on native coronary artery disease and overall cardiovascular outcomes. The role and the choice of enhanced antiplatelet/anticoagulation/lipid/glucose-modulating therapies following CABG should be better defined and deserves further investigation. Additional studies are required to identify new therapeutic target addressing the specific multifactorial nature of the graft CV disease and identifying the best preventive strategies for long-term graft patency.

Drug-Eluting Stent Versus Coronary Artery Bypass Grafting for Diabetic Patients With Multivessel and/or Left Main Coronary Artery Disease: A Meta-Analysis

With the development of stent design and surgical techniques, the relative benefit of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and complex coronary artery disease are highly debated. This meta-analysis was conducted to compare the outcomes of drug-eluting stent (DES) implantation and CABG in these cohorts. A comprehensive search of PubMed, Embase, and Cochrane Library up to January 4, 2018, was performed. Only randomized controlled trials (RCTs), subgroup analysis from RCTs, or adjusted observational studies were eligible. Five RCTs and 13 adjusted observational studies involving 17 532 patients were included. Overall, PCI with DES was significantly associated with higher risk of all-cause mortality (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.05-1.29), myocardial infarction (MI; HR: 1.69, 95% CI: 1.43-2.00), and repeat revascularization (HR: 3.77, 95% CI: 2.76-5.16) compared with CABG. Nevertheless, the risk of stroke was significantly lower in the DES group (HR: 0.67, 95% CI: 0.54-0.83). The incidence of the composite end point of death, MI, or stroke was comparable between the 2 groups (HR: 0.99, 95% CI: 0.84-1.17). Despite the higher risk of stroke, CABG was better than PCI with DES for diabetic patients with multivessel and/or left main coronary artery disease.

Use of Multifactorial Treatments to Address the Challenge of Translating Experimental Myocardial Infarct Reduction Strategies

Myocardial tissue damage that occurs during an ischemic event leads to a spiraling deterioration of cardiac muscle structural and functional integrity. Reperfusion is the only known efficacious strategy and is the most commonly used treatment to reduce injury and prevent remodeling. However, timing is critical, and the procedure is not always feasible for a variety of reasons. The complex molecular basis for cardioprotection has been studied for decades but formulation of a viable therapeutic that can significantly attenuate myocardial injury remains elusive. In this review, we address barriers to the development of a fruitful approach that will substantially improve the prognosis of those suffering from this widespread and largely unmitigated disease. Furthermore, we proffer that ephrinA1, a candidate molecule that satisfies many of the important criteria discussed, possesses robust potential to overcome these hurdles and thus offers protection that surpasses the limitations currently observed.

The Real-World Cost-Effectiveness of Coronary Artery Bypass Surgery Versus Stenting in High-Risk Patients: Propensity Score-Matched Analysis of a Single-Centre Experience

BACKGROUND

There are limited economic evaluations comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease (MVCAD) in contemporary, routine clinical practice.

OBJECTIVE

The aim was to perform a cost-effectiveness analysis comparing CABG and PCI in patients with MVCAD, from the perspective of the Australian public hospital payer, using observational data sources.

METHODS

Clinical data from the Melbourne Interventional Group (MIG) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries were analysed for 1022 CABG (treatment) and 978 PCI (comparator) procedures performed between June 2009 and December 2013. Clinical records were linked to same-hospital admissions and national death index (NDI) data. The incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided were evaluated. The propensity score bin bootstrap (PSBB) approach was used to validate base-case results.

RESULTS

At mean follow-up of 2.7 years, CABG compared with PCI was associated with increased costs and greater all-cause mortality, but a significantly lower rate of MACCE. An ICER of $55,255 (Australian dollars)/MACCE avoided was observed for the overall cohort. The ICER varied across comparisons against bare metal stents (ICER $25,815/MACCE avoided), all drug-eluting stents (DES) ($56,861), second-generation DES ($42,925), and third-generation of DES ($88,535). Moderate-to-low ICERs were apparent for high-risk subgroups, including those with chronic kidney disease ($62,299), diabetes ($42,819), history of myocardial infarction ($30,431), left main coronary artery disease ($38,864), and heart failure ($36,966).

CONCLUSIONS

At early follow-up, high-risk subgroups had lower ICERs than the overall cohort when CABG was compared with PCI. A personalised, multidisciplinary approach to treatment of patients may enhance cost containment, as well as improving clinical outcomes following revascularisation strategies.

Effects of Percutaneous Coronary Intervention on Viable Myocardium and Heart Function of Diabetic Patients With Chronic Total Occlusion

OBJECTIVE

The aim of this study was to compare the effects of percutaneous coronary intervention (PCI) on coronary chronic total occlusion patients with (DM) or without (NDM) diabetes mellitus.

METHODS

A total of 78 patients were divided into DM group and NDM group according to whether the patient has DM. The results of PCI were analyzed using quantitative coronary analysis. In addition, all the patients underwent Tc-MIBI (methoxyisobutylisonitrile) single-photon emission computed tomography (SPECT) and ultrasonic cardiogram in the first week and the sixth month after PCI to evaluate PCI results. During the 6-month follow-up, major adverse cardiac event (MACE) was recorded and analyzed as well.

RESULTS

The first and second classes of collateral circulation between the 2 groups have significant differences (P < 0.05). Left ventricular end-diastolic volume index and left ventricular end-systolic volume index were decreased at the sixth month compared with those at the first week. Left ventricular ejection fraction was significantly increased. In both groups, the defect size significantly reduced, and percentage of radionuclide scintigraphic count significantly increased between rest and nitroglycerin interventional SPECT. After 6 months, both groups repeated nitroglycerin interventional SPECT, which showed that defect size was significantly reduced, and the percentage of radionuclide scintigraphic count was significantly increased compared with those of the first week. During the 6-month follow-up, the incidence of MACE between the 2 groups had no significant difference.

CONCLUSIONS

Percutaneous coronary intervention has beneficial effects on heart functions and MACE when performed on chronic total occlusion patients with and without DM.

CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting

BACKGROUND

Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES).

OBJECTIVES

This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG).

METHODS

We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts.

RESULTS

BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001).

CONCLUSIONS

Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.

Coronary artery bypass grafting versus drug-eluting stents in patients with severe coronary artery disease and diabetes mellitus: systematic review and meta-analysis

BACKGROUND

A comprehensive meta-analysis was performed to evaluate the comparative benefits of coronary artery bypass grafting (CABG) versus drug-eluting stents (DES) in patients with diabetes mellitus and severe coronary artery disease (CAD).

METHODS

A comprehensive literature search of PubMed, Embase, and ScienceDirect was undertaken. References cited with the papers were also checked to identify relevant articles.

RESULTS

In all, four randomized controlled trials, two prospective registries, and 11 retrospective studies were identified for review. Pooled analysis demonstrated that DES was associated with lower all-cause mortality at Day 30. However, there was no significant difference between CABG and DES in mortality at 12 months and at maximum follow-up. Furthermore, DES was associated with lower overall and major adverse cardiac and cerebrovascular events (MACCE)-free survival, as well as a higher incidence of myocardial infarction and repeat revascularization. In contrast, CABG was associated with an increased risk of stroke.

CONCLUSIONS

For patients with diabetes mellitus and severe CAD, CABG is superior to DES in that it significantly improves overall and MACCE-free survival and reduces the incidence of myocardial infarction and repeat revascularization in the long term, although it is associated with greater perioperative risk and a higher incidence of stroke. Therefore, CABG should remain the gold standard for these patients.

Comparing mortality and myocardial infarction between coronary artery bypass grafting and drug-eluting stenting in patients with diabetes mellitus and multivessel coronary artery disease: a meta-analysis

INTRODUCTION

We aim to compare the midterm outcomes between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in diabetic patients who had multivessel coronary artery diseases (CAD).

MATERIAL AND METHODS

A comprehensive literature search was conducted to identify the related clinical studies with a follow-up for 1 year at least. The endpoints were death, myocardial infarction, and major adverse cardiac and cerebrovascular events (MACCE).

RESULTS

Finally, the analysis of ten studies involving 5,264 patients showed that patients with CABG had worse baseline characteristics, a higher rate of stable angina pectoris, a higher percentage of triple-vessel disease, higher incidence of chronic total occlusion and a higher SYNTAX score. However, there was no significant difference in mortality between the two groups. Additionally, the rates of myocardial infarction and MACCE were markedly decreased in the CABG group.

CONCLUSIONS

The strategy of CABG is better than PCI for diabetic patients with multivessel CAD. The CABG can significantly reduce the rates of myocardial infarction and MACCE and is comparable in mortality despite the worse baseline characteristics.

Update on interventional cardiology

This article provides a detailed review of the most important studies on interventional cardiology reported in publications or presentations during the year 2012. With regard to coronary interventions, ST-elevation myocardial infarction is extensively addressed in studies focusing on the relevance of reducing the reperfusion time and the utility of various devices and pharmacological strategies in primary angioplasty. Multiple comparative studies involving different generations of drug-eluting stents are available and indicate a favorable progression in terms of safety and efficacy. The risk of late thrombosis with the new generations of drug-eluting stents seems to be equivalent to that observed with bare-metal stents. The clinical outcomes with these stents in the elderly, in left main coronary artery, or in multivessel disease have also been the subject of important trials. Among the studies on intracoronary diagnostic techniques, those correlating imaging and pressure-based techniques are of special interest. The percutaneous treatment of structural heart disease, particularly transcatheter aortic valve implantation, followed by mitral repair, continues to be the subject of a great number of publications. Finally, renal denervation is currently being widely discussed in the literature.

Meta-analysis of 14 trials comparing bypass grafting vs drug-eluting stents in diabetic patients with multivessel coronary artery disease

BACKGROUND AND AIM

Clinical trials have reported lower mortality and repeated revascularization rate in diabetic patients treated with coronary artery bypass grafting (CABG) as compared to percutaneous revascularization. However, these studies were conducted in the era of bare-metal stents. Therefore, we performed a meta-analysis to compare CABG to PCI with drug-eluting stents (DES) in diabetic patients with multivessel and/or left main disease.

METHODS AND RESULTS

The literature was scanned by formal search of electronic databases (Medline, EMBASE, and Cochrane databases), and major international scientific session abstracts from 2000 to 2013. Primary endpoint was mortality. A total of 14 (4 randomized and 10 non-randomized) trials were finally included, with a total of 7072 patients. Up to 5 years follow-up, CABG was associated with a reduction in mortality (7.3% vs 10.4%, OR[95%CI] = 0.65[0.55-0.77], p < 0.0001; phet = 0.00001), with similar results in both RCTs (OR[95%CI] = 0.64[0.50-0.82], p = 0.0005) and NRCTs (OR[95%CI] = 0.75[0.6-0.94)], p = 0.01) (p int = 0.93). A significant relationship was observed between risk profile and benefits in mortality with CABG (p < 0.001). CABG reduced target vessel revascularization (TVR; 5.2% vs 15.7%, OR[95%CI] = 0.30[0.25-0.36], p < 0.00001, p het = 0.02), with a relationship between risk profile and the benefits from CABG as compared to DES (p < 0.0001). CABG was associated with a lower rate of MACCE (14.9% vs 22.9%, OR[95%CI] = 0.59[0.51-0.67], p < 0.00001, p het<0.00001) but higher risk of CVA (3.6% vs 1.4%, OR[95%CI] = 2.34[1.63-3.35], p < 0.00001, p het = 0.71).

CONCLUSIONS

The present meta-analysis demonstrates that among diabetic patients with multivessel disease and/or left main disease, CABG provides benefits in mortality and TVR, especially in high-risk patients but it is counterbalanced by a higher risk of stroke. Future trials are certainly needed in the era of new DES and improved antiplatelet therapies.

Comparing coronary artery bypass grafting with drug-eluting stenting in patients with diabetes mellitus and multivessel coronary artery disease: a meta-analysis

OBJECTIVES

Although drug-eluting stents (DESs) reduce the rate of target vessel revascularization compared with bare-metal stents, the results of DESs for patients with diabetes and multivessel coronary artery disease (CAD) in the DES era are inconsistent. This meta-analysis was undertaken to assess the efficacy and safety of coronary artery bypass grafting (CABG) compared with drug-eluting stent implantation in patients with diabetes mellitus and multivessel coronary artery disease.

METHODS

We conducted a search of Medline, EMBASE from January 2003 to July 2013 by two reviewers independently, using the terms 'coronary artery bypass graft surgery', 'drug-eluting stent', 'sirolimus-eluting stent', 'paclitaxel-eluting stent', 'diabetes mellitus' and 'multivessel disease', according to established criteria. Studies comparing CABG with DES in patients with diabetes and multivessel CAD with a minimum follow-up of 1 year were included.

RESULTS

Thirteen studies including 6653 patients with diabetes (3237 who underwent CABG and 3416 who underwent DES implantation) met the selection criteria. The mean follow-up period was 2.9 years (range 1-5). Compared with DES, CABG was associated with a lower risk for major adverse cardiac events (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.46-0.58), driven mainly by a lower risk for repeat revascularization (OR 0.29, 95% CI 0.23-0.35). There was no significant difference with regard to death (OR 0.89, 95% CI 0.75-1.05). Patients in the CABG group had a higher risk for stroke events (OR 2.09, 95% CI 1.45-3.02).

CONCLUSIONS

Percutaneous coronary intervention with DES in patients with diabetes and multivessel CAD is safe, but has a high risk of long-term repeat revascularization. CABG should remain the standard procedure for diabetic patients with multivessel CAD.