Bypass versus drug-eluting stents at three years in SYNTAX patients with diabetes mellitus or metabolic syndrome. Ann Thorac Surg. 2011;92:2140-2146. [PMID: 21967819 DOI: 10.1016/j.athoracsur.2011.06.028]

CABG versus PCI in the Treatment of Unprotected Left Main Disease in Diabetics: A Literature Review

The approach to left main coronary artery disease (CAD) in diabetic patients has been extensively debated. Diabetic patients have an elevated risk of left main disease in addition to multivessel disease. Previous trials have shown increased revascularization rates in percutaneous coronary intervention compared with coronary artery bypass grafting (CABG) but overall comparable outcomes, although many of these studies were not using the latest stent technology or CABG with arterial revascularization. Our aim is to review the most recent trials that have recently published long-term follow-up, as well as other literature pertaining to left main disease in diabetic patients. Furthermore, we will be discussing some future treatment strategies that could likely create a paradigm shift in how left main CAD is managed.

Impact of Body Composition Indices on Ten-year Mortality After Revascularization of Complex Coronary Artery Disease (From the Syntax Extended Survival Trial)

Numerous studies have demonstrated a paradoxical association between higher baseline body mass index (BMI) and lower long-term mortality risk after coronary revascularization, known as the "obesity paradox", possibly relying on the single use of BMI. The current study is a post-hoc analysis of the SYNTAX Extended Survival (SYNTAXES) trial, which is the extended follow-up of the SYNTAX trial comparing percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) in patients with left-main coronary artery disease (LMCAD) or three-vessel disease (3VD). Patients were stratified according to baseline BMI and/or waist circumference (WC). Out of 1,800 patients, 1,799 (99.9%) and 1,587 (88.2%) had available baseline BMI and WC data, respectively. Of those, 1,327 (73.8%) patients had High BMI (≥25 kg/m²), whereas 705 (44.4%) patients had High WC (>102 cm for men or >88 cm for women). When stratified by both BMI and WC, 10-year mortality risk was significantly higher in patients with Low BMI/Low WC (adjusted hazard ratio [HR]: 1.65; 95% confidence interval [CI]: 1.09 to 2.51), Low BMI/ High WC (adjusted HR: 2.74; 95% CI: 1.12 to 6.69), or High BMI/High WC (adjusted HR: 1.59; 95% CI: 1.11 to 2.27) compared to those with High BMI/Low WC. In conclusion, the "obesity paradox" following coronary revascularization would be driven by low long-term mortality risk of the High BMI/Low WC group. Body composition should be assessed by the combination of BMI and WC in the appropriate evaluation of the long-term risk of obesity in patients with LMCAD or 3VD.

Impact of Diabetes Mellitus on Outcomes after High-Risk Interventional Coronary Procedures

An increasing number of patients with coronary artery disease are at high operative risk due to advanced age, severe comorbidities, complex coronary anatomy, and reduced ejection fraction. Consequently, these high-risk patients are often offered percutaneous coronary intervention (PCI) as an alternative to coronary artery bypass grafting (CABG). We aimed to investigate the outcome of patients with diabetes mellitus (DM) undergoing high-risk PCI. We analyzed consecutive patients undergoing high-risk PCI (period 01/2016-08/2018). In-hospital major adverse cardiac and cerebrovascular events (MACCEs), defined as in-hospital stroke, myocardial infarction and death, and the one-year incidence of death from any cause were assessed in patients with and without DM. There were 276 patients (age 70 years, 74% male) who underwent high-risk PCI. Eighty-six patients (31%) presented with DM (insulin-dependent DM: n = 24; non-insulin-dependent DM: n = 62). In-hospital MACCEs occurred in 9 patients (3%) with a non-significant higher rate in patients with DM (n = 5/86, 6% vs. n = 4/190 2%; p = 0.24). In patients without DM, the survival rate was insignificantly higher than in patients with DM (93.6% vs. 87.1%; p = 0.07). One-year survival was not significantly different in DM patients with more complex coronary artery disease (SYNTAX I-score ≤ 22: 89.3% vs. > 22: 84.5%; p = 0.51). In selected high-risk patients undergoing high-risk PCI, DM was not associated with an increased incidence of in-hospital MACCEs or a decreased one-year survival rate.

Effectiveness of Clinical, Surgical and Percutaneous Treatment to Prevent Cardiovascular Events in Patients Referred for Elective Coronary Angiography: An Observational Study

Purpose

To ascertain the most appropriate treatment for chronic, stable, coronary artery disease (CAD) in patients submitted to elective coronary angiography.

Patients and Methods

A total of 814 patients included in the prospective cohort study were referred for elective coronary angiography and were followed up on average for 6±1.9 years. Main outcomes were all-cause death, cardiovascular death, non-fatal myocardial infarction (MI) and stroke and late revascularization and their combinations as major adverse cardiac and cerebral events (MACCE): MACCE-1 included cardiovascular death, nonfatal MI, and stroke; MACCE-2 was MACCE-1 plus late revascularization. Survival curves and adjusted Cox proportional hazard models were used to explore the association between the type of treatment and outcomes.

Results

All-cause death was lower in participants submitted to percutaneous coronary intervention (PCI) (0.41, 0.16-1.03, P=0.057) compared to medical treatment (MT). Coronary-artery bypass grafting (CABG) had an overall trend for poorer outcomes: cardiovascular death 2.53 (0.42-15.10), combined cardiovascular death, nonfatal MI, and stroke 2.15 (0.73-6.31) and these events plus late revascularization (2.17, 0.86-5.49). The corresponding numbers for PCI were 0.27 (0.05-1.43) for cardiovascular death, 0.77 (0.32-1.84) for combined cardiovascular death, nonfatal MI, and stroke and 2.35 (1.16-4.77) with the addition of late revascularization. These trends were not influenced by baseline blood pressure, left ventricular ejection fraction and previous MI. Patients with diabetes mellitus had a significantly higher risk of recurrent revascularization when submitted to PCI than CABG.

Conclusion

Patients with confirmed CAD in elective coronary angiography do not have a better prognosis when submitted to CABG comparatively to medical treatment. Patients treated with PCI had a trend for the lower incidence of combined cardiovascular events, at the expense of additional revascularization procedures. Patients without significant CAD had a similar prognosis than CAD patients treated with medical therapy.

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.

Diabetes and periprocedural outcomes in patients treated with rotablation during percutaneous coronary interventions

BACKGROUND

This study is to assess differences in periprocedural outcomes among diabetic and non-diabetic patients treated with percutaneous coronary intervention (PCI) and rotational atherectomy (RA).

METHODS

Under assessment were 221,187 patients from the Polish Cardiovascular Intervention Society national registry (ORPKI) including all PCIs performed in Poland in 2015 and 2016. Data was extracted of 975 patients treated with RA - 336 (34.5%) diabetics and 639 (65.5%) non-diabetics. Periprocedural complications were defined as overall rate or particular complications such as deaths, no-reflows, perforations, dissections, cerebral strokes or bleedings.. Multivariate analysis was performed to assess predictors of periprocedural complications.

RESULTS

The mean age was similar in diabetics and non-diabetics (70.9 ± 9.0 vs. 72.1 ± 9.9; p = 0.06). Diabetics were more often females (p < 0.01), with arterial hypertension (p < 0.01), kidney failure (p < 0.01) and prior myocardial infarction (p = 0.01). No significant differences were observed in overall or individual periprocedural complications and angiographic success was expressed as thrombolysis in myocardial infarction grade 3 flow after PCI. At baseline, de-novo lesions accounted for 96.5% in diabetics and 99% in non-diabetics (p < 0.01), while overall rate of restenosis was 3.5% and 1%, respectively (p < 0.01). Diabetes was an independent predictor of periprocedural complications in the overall group of patients treated with PCI (OR 1.11, 95% CI 1.04-1.194; p < 0.001).

CONCLUSIONS

The negative impact of diabetes on the incidence of periprocedural complications and angiographic effectiveness in the group of patients treated with RA is mitigated in the comparison to the non-RA group.

Coronary Artery Disease and Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is a major risk factor of coronary artery diseases (CAD). Clinical outcomes in CAD with T2DM are poor despite improvement in medications and intervention devices. Coronary artery bypass grafting (CABG) is superior to percutaneous coronary intervention (PCI) in treating diabetic patients with multivessel coronary artery diseases (MVD). However, selecting a revascularization strategy should depend not only on the lesion complexity but also on the patient's background and comorbidities. In addition, comprehensive risk management with medical and non-pharmacological therapies is important, as is confirmation of whether risk managements are appropriately achieved. Recently, novel anti-diabetic drugs have been demonstrated to have effectiveness in reducing cardiovascular events, which was independent of their glucose-lowering effect. Furthermore, non-pharmacological interventions using exercise and diet during the earlier stages of abnormal glucose metabolism might be beneficial in preventing the development or progression of T2DM and reducing the incidence of cardiovascular events.

Multivessel Revascularization in Shock and High-Risk Percutaneous Coronary Intervention

This review explores the usefulness of multivessel revascularization with percutaneous coronary intervention in patients with multivessel obstructive coronary artery disease (CAD) presenting with and without cardiogenic shock. We also evaluate the literature regarding complete versus incomplete revascularization for patients with cardiogenic shock, acute coronary syndromes, and stable coronary artery disease.

Body Mass Index Is Associated With Differential Rates of Coronary Revascularization After Cardiac Catheterization

BACKGROUND

The association of obesity with coronary revascularization procedures is not clear. We examined rates of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) associated with obesity while accounting for the severity of coronary disease and diabetes status.

METHODS

Patients who underwent cardiac catheterization were stratified according to coronary anatomy risks and diabetes status. Within each stratum, using normal body mass index (BMI) (18.5-24.9 kg/m²) as a reference, the associations of overweight (25.0-29.9 kg/m²), obese class I (30.0-34.9 kg/m²), obese class II (35.0-39.9 kg/m²), and obese class III (≥ 40.0 kg/m²) with the likelihood of receiving CABG and PCI were assessed while adjusting for clinical covariates.

RESULTS

Of 56,722 patients analyzed, overall use of revascularization was higher in the overweight, obese class I, and obese class II groups (overweight: adjusted hazard ratio [aHR], 1.10; 95% confidence interval [CI], 1.06-1.13; obese class I: aHR, 1.08; 95% CI, 1.05-1.12; obese class II: aHR,1.05; 95% CI, 1.01-1.10), whereas it was lower in the obese class III group (aHR, 0.91; 95% CI, 0.85-0.97) compared with normal BMI. In the subgroup with high-risk coronary anatomy and diabetes, all obese classes had higher rates of PCI (obese class I: aHR,1.24; 95% CI, 1.08-1.42; obese class II: aHR,1.27; 95% CI, 1.07-1.49, obese class III: aHR,1.37; 95% CI, 1.12-1.67) than the normal BMI group.

CONCLUSIONS

Our results showed that BMI is associated with differential rates of coronary revascularization. In patients with high-risk coronary anatomy and diabetes, clinical appropriateness of higher rates of PCI associated with obesity warrants further investigation.

Determining the Most Appropriate Mode of Coronary Artery Revascularisation in Patients With Diabetes

Obstructive coronary artery disease is a common cause of morbidity and mortality among patients with diabetes mellitus (DM). Previous research has demonstrated that the clinical sequelae of coronary artery disease remains the most common cause of death in this population. As a result numerous observational studies and randomised clinical trials have evaluated the timing and mode of coronary artery revascularisation within this population. In this review, we survey the currently available data informing the indications and optimal method of coronary revascularisation for diabetic patients.

Has the difference in mortality between percutaneous coronary intervention and coronary artery bypass grafting in people with heart disease and diabetes changed over the years? A systematic review and meta-regression

OBJECTIVES

To examine the difference in outcome between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), to see if it has changed over the years in diabetics deemed eligible for both treatments; and to contrast the long-term mortality findings with those in non-diabetics.

DESIGN

Meta-analyses using data from randomised controlled trials found by searches on MEDLINE, EMBASE and the Cochrane Controlled Trials Register, from their inception until March 2015.

SETTING

Studies had to be randomised controlled trials comparing PCI with CABG.

PARTICIPANTS

Those taking part in the studies had to have multivessel cardiac or left main artery cardiac disease and be deemed eligible for both treatments.

INTERVENTIONS

PCI or CABG.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was all cause mortality. Secondary outcomes were a composite of mortality, stroke and myocardial infarction; cardiovascular death; and MACCE (Major Adverse Cardiac or Cerebrovascular Event). The longest follow-up was used in the analysis.

RESULTS

Among 14 studies (4868 diabetics) reported over three decades, meta-regression shows no relationship between the year of publication and the difference in long term all cause mortality between PCI and CABG. CABG has maintained an approximately 30% mortality advantage compared to PCI. The other outcomes used showed the same lack of change over the years. These findings held true among insulin-requiring and non-insulin-requiring diabetics. However, among non-diabetics included in the 14 studies, there was no difference in mortality outcome between PCI and CABG.

CONCLUSIONS

The difference in outcome between PCI and CABG in diabetics has not narrowed from the beginning-with balloon angioplasty to current PCI-with the second generation of drug eluting stents. In contrast to the non-diabetics, there is a persistent 30% benefit in all cause mortality favouring CABG in diabetics, and this should be a major factor in treatment recommendation.

Revascularization in patients with diabetes: PCI or CABG or none at all

Patients with diabetes have a high incidence of coronary artery disease, with particularly high rates of acute coronary syndromes and mortality. Revascularization by coronary artery bypass grafting was found to be effective in reducing angina and mortality in patients with extensive coronary artery disease over 30 years ago. Percutaneous coronary intervention, particularly with drug-eluting stents, has more recently been demonstrated to reduce recurrent angina and improve quality of life in diabetic patients with less extensive coronary artery disease. Most recently, coronary artery bypass grafting has been shown to be superior to percutaneous coronary intervention in improving mortality in patients with diabetes and three-vessel coronary artery disease who are not at high surgical risk. The role of coronary artery bypass grafting vs. percutaneous coronary intervention in patients who have less extensive coronary artery disease and/or higher surgical risk has not been fully elucidated. Newer treatment strategies, such as percutaneous coronary intervention with second-generation drug-eluting stents, use of fractional flow reserve guidance, or hybrid revascularization combining minimally invasive coronary artery bypass grafting with percutaneous coronary intervention, may result in further improvements in outcomes in patients with diabetes and coronary artery disease.

Proposed Recommendations for Myocardial Revascularisation

This discussion paper presents proposed recommendations for myocardial revascularisation in the Australasian clinical setting based on underlying evidence-based principles and an understanding of local factors which may limit the provision of ideal practice. Recommendations are proposed for myocardial revascularisation in common clinical scenarios and also for special categories, such as patients with diabetes, chronic renal impairment, advanced age, chronic total occlusions and Indigenous patients.

Coronary artery bypass grafting in diabetics: A growing health care cost crisis

OBJECTIVES

To determine 4-decade temporal trends in the prevalence of diabetes and cardiovascular risk factors among patients undergoing coronary artery bypass grafting (CABG) and to compare in-hospital outcomes, resource utilization, and long-term survival after CABG in diabetics versus nondiabetics.

METHODS

From January 1972 to January 2011, 10,362 pharmacologically treated diabetics and 45,139 nondiabetics underwent first-time CABG. Median follow-up was 12 years. Direct technical cost data were available from 2003 onward (n = 4679). Propensity matching by diabetes status was used for outcome comparisons. Endpoints were in-hospital adverse events, resource utilization, and long-term survival.

RESULTS

Diabetics undergoing CABG increased from 7% in the 1970s to 37% in the 2000s. Their outcomes were worse, with more (P < .05) in-hospital deaths (2.0% vs 1.3%), deep sternal wound infections (2.3% vs 1.2%), strokes (2.2% vs 1.4%), renal failure (4.0% vs 1.3%), and prolonged postoperative hospital stay (9.6% vs 6.0%); and their hospital costs were 9% greater (95% confidence interval 7%-11%). Survival after CABG among diabetics versus nondiabetics at 1, 5, 10, and 20 years was also worse: 94% versus 94%, 80% versus 84%, 56% versus 66%, and 20% versus 32%, respectively. Propensity-matched patients incurred similar costs, but the prevalence of postoperative deep sternal wound infections and stroke, as well as long-term survival, remained worse in diabetics.

CONCLUSIONS

Diabetes is both a marker for high-risk, resource-intensive, and expensive care after CABG and an independent risk factor for reduced long-term survival. These issues, coupled with the increasing proportion of patients needing CABG who have diabetes, are a growing challenge in reining in health care costs.

Coronary artery disease in type 2 diabetes mellitus: Recent treatment strategies and future perspectives

Patients with type 2 diabetes mellitus (T2DM) are at a higher risk of developing coronary artery disease (CAD) than are non-T2DM patients. Moreover, the clinical outcomes in CAD with T2DM are poor despite improvements in medications and other interventions. Coronary artery bypass grafting is superior to percutaneous coronary intervention in treating multivessel coronary artery disease in diabetic patients. However, selecting a revascularization strategy depends not only on the lesion complexity but also on the patient’s medical history and comorbidities. Additionally, comprehensive risk management with medical and non-pharmacological therapies is important, as is confirmation regarding whether the risk-management strategies are being appropriately achieved. Furthermore, non-pharmacological interventions using exercise and diet during the earlier stages of glucose metabolism abnormalities, such as impaired glucose tolerance, might be beneficial in preventing the development or progression of T2DM and in reducing the occurrence of cardiovascular events.

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.

Outcomes of Primary Percutaneous Coronary Intervention for Patients with Previous Coronary Artery Bypass Grafting Presenting with STsegment Elevation Myocardial Infarction

Background:

There are limited data on outcomes of patients with previous coronary artery bypass grafting (CABG) presenting acutely as ST-segment elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PPCI).

Objectives:

To compare outcomes in STEMI patients undergoing PPCI with or without previous CABG surgery.

Methods:

An all-comer single-centre observational registry from a cardiothoracic centre in UK. All consecutive patients presenting for PPCI between 2007 and 2012 were included. Electronic records were used to extract relevant information. Mortality data were obtained from the Office of National Statistics. Overall median follow-up period was 1.7 years (intraquartile range 0.9-2.5).

Results:

Complete data were available for 2133 (97%) patients. 47-patients had previous history of CABG. Out of these, the infarct related artery (IRA) was native vessel in 22 and graft in 25 patients. Post re-vascularization TIMI flow was inferior in CABG cohort (<TIMI 3 flow in 17% vs. 10%, p=0.012) and they were less likely to achieve acute reperfusion (TIMI 0 in 9% vs. 3%, p=0012). In-hospital-mortality was not different in both groups (2%vs.4%, p=0.23). 30-day (HR 0.54; 95%CI 0.17-1.73; P=0.301), 1-year-mortality (HR 0.77; 95%CI 0.31-1.87; P=0.56) and over a median follow-up of 1.7 years (HR 1.1; 95%CI 0.54-2.27; P=0.79) were also not different.

Conclusion:

Patients presenting with STEMI to PPCI service with history of CABG are less likely to achieve acute reperfusion and have worse angiographic outcomes. Post PPCI, the prior CABG patients do not seem to have worse shortterm and long-term prognosis.

Percutaneous coronary invervention versus coronary artery bypass grafting: a meta-analysis

OBJECTIVE

To compare the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with coronary artery disease.

METHODS

MEDLINE, Embase, and Cochrane Central were searched, and randomized controlled trials were included. Outcomes were assessed at maximum available follow-up.

RESULTS

This meta-analysis includes 31 trials with 15,004 patients. As regards death, more patients died after PCI compared with CABG across all types of patients (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.3; P = .05) as well as in patients with multivessel disease (OR, 1.2; 95% CI, 1.0-1.4; P = .02) or diabetes (OR, 1.6; 95% CI, 1.2-2.1; P < .01). Myocardial infarction occurred as frequently after PCI (OR, 1.2; 95% CI, 0.9-1.5; P = .28). Repeat revascularization was more common after PCI (OR, 4.5; 95% CI, 3.5-5.8; P < .01), with a progressive decline in ORs from the pre-stent era (OR, 7.0; 95% CI, 5.1-9.7; P < .01), to the bare metal stent era (OR, 4.5; 95% CI, 3.6-5.5; P < .01), and to the drug-eluting stent era (OR, 2.5; 95% CI, 1.8-3.4; P < .01). Stroke was more common after CABG (OR, 0.7; 95% CI, 0.5-0.9; P = .01).

CONCLUSIONS

Compared with PCI, CABG had a lower risk of death in multivessel disease or diabetes patients eligible for either intervention, a lower risk of repeat revascularization, but a higher risk of stroke.

Surgical versus percutaneous revascularization in patients with multivessel coronary artery disease

New-generation stents have been continually developed in order to improve the safety and efficacy of percutaneous coronary intervention (PCI). Several randomized clinical trials have been conducted over the last two decades to compare the outcomes of PCI with coronary artery bypass grafting (CABG), which has been the time-tested treatment of multivessel coronary artery disease. The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial is one of the most recent and largest randomized controlled trials comparing PCI using the paclitaxel-eluting first-generation stent with CABG and was uniquely formulated to represent "real world" daily practice. The final 5-year main results of this trial and its various prespecified subgroups have been published in the past year. These results will form the basis of the new guidelines that will be published in the near future. This review is a compilation of the results of the SYNTAX trial and comparisons with other contemporary trials, meta-analyses, and retrospective studies of large registries and how these results help cardiac surgeons and cardiologists in judicious decision-making for their patients with multivessel coronary artery disease requiring revascularization.

Drug-eluting stents versus coronary artery bypass grafting in diabetic patients with multi-vessel disease: a meta-analysis

BACKGROUND

Data comparing long-term results after percutaneous intervention with drug-eluting stents (DES/PCI) and coronary artery grafting (CABG) in diabetic patients (pts) with multi-vessel disease is conflicting. We have conducted a systematic review and meta-analysis to help answer this issue.

METHODS

MEDLINE, WoS, and Scopus were systematically analysed to yield observational studies (OBS) or randomised controlled trials (RCT) fulfilling search criteria. Odds ratio (OR) for studied end-points were obtained with inverse variance random effects analysis. Results are presented with 95% confidence intervals with significance at p<0.05.

RESULTS

A total of 14 studies (5 RCT; 9 OBS) including more than 5000 pts were selected for review. Early/30-day was lower in the DES/PCI cohort [OR 0.49(0.27, 0.88); p=0.02; I(2)=0%]. Post-procedural stroke was higher in the CABG (1.8%) cohort compared to DES/PCI (0.17%; p<0.01). A pooled analysis of RCT demonstrated that stroke rate was similar in both cohorts at the end of one year [OR 0.84(0.19, 3.74); p=0.82; I(2) =67%]. During a follow-up of three to five years, repeat intervention was much higher in the DES/PCI cohort [OR 3.02(2.13, 4.28; p<0.01]. The odds of suffering an adverse cardiovascular /cerebrovascular event were 1.71 (1.27, 2.3) times higher in the DES/PCI cohort compared to CABG.

CONCLUSION

In diabetic patients with multivessel disease, early mortality is lower in the DES/PCI cohort. While peri-procedural stroke rates are lower with PCI, they are, however, comparable at the end of one year. Use of drug-eluting stents leads to a higher rate of re-intervention and major cardiovascular/cerebrovascular events at three to five years.

Interventions for coronary artery disease (surgery vs angioplasty) in diabetic patients

Patients with diabetes develop more widespread and more severe atherosclerotic coronary artery disease than patients without diabetes. Medical management of this coronary disease is inferior to revascularization for more complex or more widespread disease. Revascularization by percutaneous intervention (PCI) for patients with diabetes is associated with high mortality and complication rates. Surgical revascularization by coronary artery bypass grafting, yields superior results to PCI for patients with diabetes and coronary artery disease. Patients with diabetes benefit from the same medical management of their coronary artery disease and secondary risk modification as patients without diabetes.

Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised controlled trials

BACKGROUND

The choice between coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) for revascularisation in patients with diabetes and multivessel coronary artery disease, who account for 25% of revascularisation procedures, is much debated. We aimed to assess whether all-cause mortality differed between patients with diabetes who had CABG or PCI by doing a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing CABG with PCI in the modern stent era.

METHODS

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from Jan 1, 1980, to March 12, 2013, for studies reported in English. Eligible studies were those in which investigators enrolled adult patients with diabetes and multivessel coronary artery disease, randomised them to CABG (with arterial conduits in at least 80% of participants) or PCI (with stents in at least 80% of participants), and reported outcomes separately in patients with diabetes, with a minimum of 12 months of follow-up. We used random-effects models to calculate risk ratios (RR) and 95% CIs for pooled data. We assessed heterogeneity using I(2). The primary outcome was all-cause mortality in patients with diabetes who had CABG compared with those who had PCI at 5-year (or longest) follow-up.

FINDINGS

The initial search strategy identified 3414 citations, of which eight trials were eligible. These eight trials included 7468 participants, of whom 3612 had diabetes. Four of the RCTs used bare metal stents (BMS; ERACI II, ARTS, SoS, MASS II) and four used drug-eluting stents (DES; FREEDOM, SYNTAX, VA CARDS, CARDia). At mean or median 5-year (or longest) follow-up, individuals with diabetes allocated to CABG had lower all-cause mortality than did those allocated to PCI (RR 0.67, 95% CI 0.52-0.86; p=0.002; I(2)=25%; 3131 patients, eight trials). Treatment effects in individuals without diabetes showed no mortality benefit (1.03, 0.77-1.37; p=0.78; I(2)=46%; 3790 patients, five trials; p interaction=0.03). We identified no differences in outcome whether PCI was done with BMS or DES. When present, we identified no clear causes of heterogeneity.

INTERPRETATION

In the modern era of stenting and optimum medical therapy, revascularisation of patients with diabetes and multivessel disease by CABG decreases long-term mortality by about a third compared with PCI using either BMS or DES. CABG should be strongly considered for these patients.

Outcomes of coronary artery interventions: comparing coronary artery bypass surgery and percutaneous coronary intervention in patients with unprotected left main stenosis

PURPOSE

The purpose of this integrative review is to examine the existing literature comparing short- and long-term outcomes of both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery (ULMCA) stenosis. CABG has long been considered the standard of treatment for ULMCA stenosis; however, advancements in the use of PCI have made it a viable alternative treatment option.

DATA SOURCES

Sixteen articles were selected from a literature search using the PubMed database, with at least 1 year of follow-up and adjustment for established risk factors.

CONCLUSIONS

The majority of studies found CABG and PCI with stenting to be comparable and equally safe treatment strategies for patients with ULMCA stenosis. Some studies found that PCI had a significantly lower risk for adverse events and mortality compared to CABG. However, a large number of studies found that PCI had a higher rate of target vessel restenosis.

IMPLICATIONS FOR PRACTICE

Advanced practice nurses have become a prominent and influential part of the healthcare delivery system. As such, advanced practice nurses should be educated on the current research about coronary artery interventions so that they may better screen, treat, and manage this patient population.

Revascularization strategies in patients with Type 2 diabetes mellitus

This review aims to describe new developments in coronary revascularization strategies for patients with pre-existing Type 2 diabetes mellitus (DM). Recommended strategies for revascularization have been an active area of study with recent important developments. In patients with Type 2 DM and multivessel coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery is the preferred method for revascularization. Patients with DM are at increased risk for diffuse cardiovascular disease due to the proinflammatory, prothrombotic effects of chronic hyperglycemia. In patients undergoing percutaneous coronary intervention, drug-eluting stents and more potent antiplatelet agents especially in those presenting with acute coronary syndromes should be employed.

Effectiveness of percutaneous coronary intervention with drug-eluting stents compared with bypass surgery in diabetics with multivessel coronary disease: comprehensive systematic review and meta-analysis of randomized clinical data

Background

Controversy persists regarding the optimal revascularization strategy for diabetic patients with multivessel coronary artery disease (MVD). Coronary artery bypass grafting (CABG) has been compared with percutaneous coronary intervention (PCI) using drug‐eluting stents (DES) in recent randomized controlled trials (RCTs).

Methods and Results

RCTs comparing PCI with DES versus CABG in diabetic patients with MVD who met inclusion criteria were analyzed (protocol registration No. CRD42013003693). Primary end point (major adverse cardiac events) was a composite of death, myocardial infarction, and stroke at a mean follow‐up of 4 years. Analyses were performed for each outcome by using risk ratio (RR) by fixed‐ and random‐effects models. Four RCTS with 3052 patients met inclusion criteria (1539 PCI versus 1513 CABG). Incidence of major adverse cardiac events was 22.5% for PCI and 16.8% for CABG (RR 1.34, 95% CI 1.16 to 1.54, P<0.0001). Similar results were obtained for death (14% versus 9.7%, RR 1.51, 95% CI 1.09 to 2.10, P=0.01), and MI (10.3% versus 5.9%, RR 1.44, 95% CI 0.79 to 2.6, P=0.23). Stroke risk was significantly lower with DES (2.3% versus 3.8%, RR 0.59, 95% CI 0.39 to 0.90, P=0.01) and subsequent revascularization was several‐fold higher (17.4% versus 8.0%, RR 1.85, 95% CI 1.0 to 3.40, P=0.05).

Conclusions

These data demonstrate that CABG in diabetic patients with MVD at low to intermediate surgical risk (defined as EUROSCORE <5) is superior to MVD PCI with DES. CABG decreased overall death, nonfatal myocardial infarction, and repeat revascularization at the expense of an increase in stroke risk.

Percutaneous coronary intervention with drug-eluting stents or coronary artery bypass surgery in subjects with type 2 diabetes

There is a debate as to whether percutaneous coronary intervention (PCI) with drug-eluting stents or coronary artery bypass surgery (CABG) is the best procedure for subjects with type 2 diabetes and coronary artery disease requiring revascularization. There is some evidence that by following these procedures, there is less further revascularization with CABG than PCI in subjects with diabetes. Two recent studies, namely, the FREEDOM (Future Revascularization Evaluation in patients with Diabetes mellitus: Optimal Management of Multivessel Disease) trial and a trial using a real-world diabetic population from a Registry have shown that the benefits of CABG over PCI in subjects with type 2 diabetes extend to lower rates of death and myocardial infarction, in addition to lower rates of revascularization. However, the rates of stroke may be higher with CABG than PCI with drug-eluting stents in this population. Thus, if CABG is going to be preferred to PCI in subjects with type 2 diabetes and multivessel coronary disease, consideration should be given as to how to reduce the rates of stroke with CABG.

Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial

OBJECTIVES

This prespecified subgroup analysis examined the effect of diabetes on left main coronary disease (LM) and/or three-vessel disease (3VD) in patients treated with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in the SYNTAX trial.

METHODS

Patients (n = 1800) with LM and/or 3VD were randomized to receive either PCI with TAXUS Express paclitaxel-eluting stents or CABG. Five-year outcomes in subgroups with (n = 452) or without (n = 1348) diabetes were examined: major adverse cardiac or cerebrovascular events (MACCE), the composite safety end-point of all-cause death/stroke/myocardial infarction (MI) and individual MACCE components death, stroke, MI and repeat revascularization. Event rates were estimated with Kaplan-Meier analyses.

RESULTS

In diabetic patients, 5-year rates were significantly higher for PCI vs CABG for MACCE (PCI: 46.5% vs CABG: 29.0%; P < 0.001) and repeat revascularization (PCI: 35.3% vs CABG: 14.6%; P < 0.001). There was no difference in the composite of all-cause death/stroke/MI (PCI: 23.9% vs CABG: 19.1%; P = 0.26) or individual components all-cause death (PCI: 19.5% vs CABG: 12.9%; P = 0.065), stroke (PCI: 3.0% vs CABG: 4.7%; P = 0.34) or MI (PCI: 9.0% vs CABG: 5.4%; P = 0.20). In non-diabetic patients, rates with PCI were also higher for MACCE (PCI: 34.1% vs CABG: 26.3%; P = 0.002) and repeat revascularization (PCI: 22.8% vs CABG: 13.4%; P < 0.001), but not for the composite end-point of all-cause death/stroke/MI (PCI: 19.8% vs CABG: 15.9%; P = 0.069). There were no differences in all-cause death (PCI: 12.0% vs CABG: 10.9%; P = 0.48) or stroke (PCI: 2.2% vs CABG: 3.5%; P = 0.15), but rates of MI (PCI: 9.9% vs CABG: 3.4%; P < 0.001) were significantly increased in the PCI arm in non-diabetic patients.

CONCLUSIONS

In both diabetic and non-diabetic patients, PCI resulted in higher rates of MACCE and repeat revascularization at 5 years. Although PCI is a potential treatment option in patients with less-complex lesions, CABG should be the revascularization option of choice for patients with more-complex anatomic disease, especially with concurrent diabetes.

An update on drug-eluting stents

OPINION STATEMENT

Coronary artery disease remains one of the major causes of morbidity and mortality worldwide. Percutaneous coronary intervention has been shown to be an effective treatment for angina pectoris, although it does not provide any prognostic benefit in stable patients. Drug-eluting stents (DES) have revolutionised the practice of interventional cardiology by permitting the percutaneous treatment of increasingly complex coronary artery lesions, which historically would have only been treated with surgery. There have been concerns with their long-term safety; however, the most recent large meta-analysis appears to suggest that these concerns are no longer a pertinent issue with the newest generation of stents. Consequently, DES are being used in complex patients and lesion types, and clinical data and guideline recommendations support this. New stent designs are also continually being developed, with the aim to further improve the safety profile of these devices. It must, however, be kept in mind that complacency following the impressive result from initial DES studies lead to, amongst others things, sub-optimal and careless stent deployment, and inappropriate patient selection, which may have ultimately contributed to the prior safety concerns. It is vital, therefore, that this is not repeated in light of the reassuring data, or with newer devices. Finally, as stent design improves, it is becoming increasingly difficult to identify meaningful and clinically relevant differences in stent performance without the requirement of a very large, expensive, randomised trial.

Diabetes as an independent predictor of high atherosclerotic burden assessed by coronary computed tomography angiography: the coronary artery disease equivalent revisited

(1) To study the prevalence and severity of coronary artery disease (CAD) in diabetic patients. (2) To provide a detailed characterization of the coronary atherosclerotic burden, including the localization, degree of stenosis and plaque composition by coronary computed tomography angiography (CCTA). Single center prospective registry including a total of 581 consecutive stable patients (April 2011-March 2012) undergoing CCTA (Dual-source CT) for the evaluation of suspected CAD without previous myocardial infarction or revascularization procedures. Different coronary plaque burden indexes and plaque type and distribution patterns were compared between patients with (n = 85) and without diabetes (n = 496). The prevalence of CAD (any plaque; 74.1 vs. 56%; p = 0.002) and obstructive CAD (≥50% stenosis; 31.8 vs. 10.3%; p < 0.001) were significantly higher in diabetic patients. The remaining coronary atherosclerotic burden indexes evaluated (plaque in LM-3v-2v with prox. LAD; SIS; SSS; CT-LeSc) were also significantly higher in diabetic patients. In the per segment analysis, diabetics had a higher percentage of segments with plaque in every vessel (2.6/13.1/7.5/10.5% for diabetics vs. 1.4/7.1/3.3/4.4% for nondiabetics for LM, LAD, LCx, RCA respectively; p < 0.001 for all) and of both calcified (19.3 vs. 9.2%, p < 0.001) and noncalcified or mixed types (14.4 vs. 7.0%; p < 0.001); the ratio of proximal-to-distal relative plaque distribution (calculated as LM/proximal vs. mid/distal/branches) was lower for diabetics (0.75 vs. 1.04; p = 0.009). Diabetes was an independent predictor of CAD and was also associated with more advanced CAD, evaluated by indexes of coronary atherosclerotic burden. Diabetics had a significantly higher prevalence of plaques in every anatomical subset and for the different plaque composition. In this report, the relative geographic distribution of the plaques within each subgroup, favored a more mid-to-distal localization in the diabetic patients.