Seven-year outcome in the Bypass Angioplasty Revascularization Investigation (BARI) by treatment and diabetic status

Drug-coated balloon-based versus drug-eluting stent-only revascularization in patients with diabetes and multivessel coronary artery disease

BACKGROUND

Data on drug-coated balloon (DCB) treatment in the context of diabetes mellitus (DM) and multivessel coronary artery disease (CAD) are limited. We aimed to investigate the clinical impact of DCB-based revascularization on percutaneous coronary intervention (PCI) in patients with DM and multivessel CAD.

METHODS

A total of 254 patients with multivessel disease (104 patients with DM) successfully treated with DCB alone or combined with drug-eluting stent (DES) were retrospectively enrolled (DCB-based group) and compared with 254 propensity-matched patients treated with second-generation DES from the PTRG-DES registry (n = 13,160 patients) (DES-only group). Major adverse cardiovascular events (MACE) comprised cardiac death, myocardial infarction, stroke, stent or target lesion thrombosis, target vessel revascularization, and major bleeding at 2 years.

RESULTS

The DCB-based group was associated with a reduced risk of MACE in patients with DM (hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.05-0.68, p = 0.003], but not in those without DM (HR 0.52, 95% CI 0.20-1.38, p = 0.167) at the 2-year follow-up. In patients with DM, the risk of cardiac death was lower in the DCB-based group than the DES-only group, but not in those without DM. In both patients with or without DM, the burdens of DES and small DES (less than 2.5 mm) used were lower in the DCB-based group than in the DES-only group.

CONCLUSIONS

In multivessel CAD, the clinical benefit of a DCB-based revascularization strategy appears to be more evident in patients with DM than in those without DM after 2 years of follow-up. (Impact of Drug-Coated Balloon Treatment in De Novo Coronary Lesion; NCT04619277).

Low Levels of Vitamin D and Silent Myocardial Ischemia in Type 2 Diabetes: Clinical Correlations and Prognostic Significance

Vitamin D deficiency has a pathogenetic and prognostic role in coronary artery disease and a key role in pain transmission. Diabetic patients have a higher risk of silent myocardial ischemia (SMI) due to diabetic neuropathy. We evaluated the correlation between SMI and Vitamin D serum levels in type 2 diabetic patients and assessed whether SMI patients had a worse survival rate than their symptomatic counterpart. We enrolled 253 patients admitted in our Cardiology Unit and compared them with 50 healthy volunteers. We created three sub-groups: symptomatic MI group (125, 32.4%); SMI group (78, 25.7%), and no-MI group (50, 41.9%). 25(OH)D levels (nmol/L) were lower in the SMI group (34.9 ± 5.8) compared to those in the symptomatic MI (49.6 ± 6.1; p = 0.01), no MI (53.1 ± 6.2; p = 0.001), and control groups (62.1 ± 6.7; p = 0.0001). 25(OH)D levels predicted SMI in diabetic patients, with an inverted odds ratio of 1.11 (p = 0.01). Symptomatic MI group survival was higher than the SMI one (6-year survival rate: 83 vs. 69%; p = 0.01). Diabetic patients with SMI had a higher mortality risk and showed lower 25(OH)D levels than the symptomatic group. This suggests the crucial role that vitamin D has in the pathogenesis of SMI.

External Validation of the FREEDOM Score for Individualized Decision Making Between CABG and PCI

BACKGROUND

Although randomized trials have established that coronary artery bypass grafting (CABG) is, on average, the most effective revascularization strategy compared with percutaneous coronary intervention (PCI) in patients with diabetes and multivessel disease (MVD), individual patients differ in many characteristics that can affect the benefits and harms of treatment. The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus) score was developed to predict different outcomes with CABG vs PCI on the basis of 8 patient characteristics and the smoking-treatment interaction.

OBJECTIVES

This study aimed to assess the ability of the 5-year major adverse cardiovascular event (MACE) model to predict treatment benefit of CABG vs PCI in the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) and BEST (Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease) trials.

METHODS

This study identified 702 patients with diabetes and MVD to mirror the FREEDOM participants. Discrimination was assessed by C-index, and calibration was assessed by calibration plots in the PCI and CABG arms, respectively. The ability of the FREEDOM score to predict treatment benefit of CABG vs PCI was assessed.

RESULTS

Overall, CABG was associated with a lower rate of 5-year MACE compared with PCI (12.4% vs 20.3%; log-rank P = 0.021) irrespective of a history of smoking (P_interaction = 0.975). Both discrimination and calibration were helpful in the PCI arm (C-index: 0.69; slope: 0.96, intercept: -0.24), but moderate in the CABG arm (C-index: 0.61; slope: 0.61; intercept: -0.53). The FREEDOM score showed some heterogeneity of treatment benefit.

CONCLUSIONS

The FREEDOM score could identify some heterogeneity of treatment benefit of CABG vs PCI for 5-year MACE. Until further prospective validations are performed, these results should be taken into consideration when using the FREEDOM score in patients with diabetes and MVD. (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery [SYNTAX]; NCT00114972) (Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease [BEST]; NCT00997828) (Future Revascularization Evaluation in Patients with Diabetes Mellitus [FREEDOM]; NCT00086450).

Effect of diabetes mellitus on long-term outcomes of surgical revascularization in patients with ischemic heart failure: a propensity score-matching study

BACKGROUND

Diabetes mellitus (DM) is an important risk factor in the long-term outcomes of surgical revascularization. However, few studies have focused on patients with ischemic heart failure (IHF) and DM, and the results are controversial. This study aimed to evaluate the effect of DM on the long-term outcomes of IHF patients undergoing coronary artery bypass grafting (CABG).

METHODS

In this propensity-matched study, data of IHF patients who underwent CABG in our hospital from January 2007 to December 2017 were analyzed. With a mean 73-month follow-up time, the patients were divided into two groups according to whether they had DM. The primary endpoint was all-cause death, and the secondary endpoint was a composite of all-cause death, stroke, recurrent myocardial infarction, and revascularization.

RESULTS

There was no significant difference in all-cause mortality between the two groups (5.8% vs. 4.1%, P = 0.216). The incidence of main adverse cardiovascular and cerebrovascular events (MACCE) in the secondary endpoint was significantly higher in the DM group than that in the non-DM group (10.4% vs. 8.1%, P = 0.023).

CONCLUSIONS

DM can negatively affect the long-term outcomes of IHF patients undergoing CABG by significantly increasing the overall incidence of MACCE, though the long-term survival does not show a significant difference between the DM and non-DM patients.

Coronary revascularization in patients with stable coronary disease and diabetes mellitus

PURPOSE OF STUDY

Diabetes mellitus accelerates the development of atherosclerosis. Patients with diabetes mellitus have higher incidence and mortality rates from cardiovascular disease and undergo a disproportionately higher number of coronary interventions compared to the general population. Proper selection of treatment modalities is thus paramount. Treatment strategies include medical management and interventional approaches including coronary artery bypass graft (CABG) surgery and percutaneous coronary interventions (PCI). The purpose of this review is to assimilate emerging evidence comparing CABG to PCI in patients with diabetes and present an outlook on the latest advances in percutaneous interventions, in addition to the optimal medical therapies in patients with diabetes.

KEY METHODS

A systematic search of PubMed, Web of Science and EMBASE was performed to identify prospective, randomized trials comparing outcomes of CABG and PCI, and also PCI with different generations of stents used in patients with diabetes. Additional review of bibliography of selected studies was also performed.

MAIN CONCLUSIONS

Most of the trials discussed above demonstrate a survival advantage of CABG over PCI in patients with diabetes. However, recent advances in PCI technology are starting to challenge this narrative. Superior stent designs, use of specific drug-eluting stents, image-guided stent deployment, and the use of contemporary antiplatelet and lipid-lowering therapies are continuing to improve the PCI outcomes. Prospective data for such emerging interventional technologies in diabetes is however lacking currently and is the need of the hour.

Frequency of restenosis after carotid endarterectomy

Introduction: Carotid artery restenosis is a significant long-term complication of carotid endarterectomy. Carotid artery restenosis is the result of neointimal hyperplasia in the early postoperative period or recurrent atherosclerotic lesions in the following period. Numerous studies have incriminated several risk factors as predisposing conditions for restenosis. The definite role of each predisposing factor, however, is still widely debated. Aim: Investigation of frequency and risk factors for restenosis after carotid endarterectomy. Material and methods: Data of 295 patients who underwent carotid endarterectomy was reviewed between 2008 and 2010. Postoperative duplex studies were performed on control examinations in the following period between 2011 and 2019. Retrospective analysis was performed to assess the effect of demographic, clinical and laboratory characteristics of patients on the development of restenosis after carotid endarterectomy. Results: Restenosis occurred in 76 (26%) patients after carotid endarterectomy, with the highest incidence during the third (33%) and fourth (25%) year of follow-up. Patients with diabetes (p = 0.048) and peripheral arterial occlusive disease (p = 0.041) had significant statistical correlation with the occurrence of restenosis, as well as parameters of lipid status - cholesterol values (p = 0.025), serum low-density lipoprotein (p = 0.036) and non highdensity lipoprotein (p = 0.041). Conclusion: The results of our study confirm the significant role of atherosclerotic risk factors in the development of carotid artery restenosis in the later postoperative period. More frequent monitoring and control of systemic risk factors in these patients is necessary in order to prevent the development of carotid artery restenosis.

Ten-year all-cause mortality according to smoking status in patients with severe coronary artery disease undergoing surgical or percutaneous revascularization

AIMS

To evaluate the impact of various smoking status on 10-year all-cause mortality and to examine a relative treatment benefit of coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) according to smoking habits.

METHODS AND RESULTS

The SYNTAX Extended Survival study evaluated vital status up to 10 years in 1800 patients with de novo three-vessel disease and/or left main coronary artery disease randomized to CABG or PCI in the SYNTAX trial. In the present analysis, patients were divided into three groups (current, former, or never smokers), and the primary endpoint of 10-year all-cause mortality was assessed according to smoking status. Smoking status was available in 1793 (99.6%) patients at the time of randomization, of whom 363 were current smokers, 798 were former smokers, and 632 were never smokers. The crude rates of 10-year all-cause mortality were 29.7% in current smokers, 25.3% in former smokers, and 25.9% in never smokers (Log-rank P = 0.343). After adjustment for imbalances in baseline characteristics, current smokers had a significantly higher risk of 10-year all-cause mortality than never smokers [adjusted hazard ratio (aHR): 2.29; 95% confidence interval (CI): 1.60-3.27; P < 0.001], whereas former smokers did not. PCI was associated with a higher risk of all-cause mortality than CABG among current smokers (HR: 1.60; 95% CI: 1.09-2.35; P = 0.017), but it failed to show a significant interaction between revascularization strategies and smoking status (Pinteraction = 0.910).

CONCLUSION

Current smokers had a higher adjusted risk of 10-year all-cause mortality, whereas former smokers did not. The treatment effect of CABG vs. PCI did not differ significantly according to smoking status.

CLINICAL TRIAL REGISTRATION

SYNTAX: ClinicalTrials.gov reference: NCT00114972; SYNTAX Extended Survival. ClinicalTrials.gov reference: NCT03417050.

High HDL-C levels reduce the risk of obstructive coronary artery disease in asymptomatic diabetics who achieved optimal glycemic control

The benefit of a high level of high-density lipoprotein cholesterol (HDL-C) against coronary atherosclerosis risk after achieving optimal glycemic control (OGC) in diabetics remains uncertain. We aimed to evaluate the association between HDL-C and obstructive coronary artery disease (CAD) according to OGC status in diabetics. We analyzed 1,114 asymptomatic diabetics who underwent coronary computed tomographic angiography in a health examination. OGC was defined as hemoglobin A1C <7.0%. Obstructive CAD was defined as the presence of plaques with ≥50% stenosis. Patients with a high HDL-C level (≥40 mg/dL and ≥50 mg/dL in males and females, respectively) showed a lower prevalence of obstructive CAD than those with a low HDL-C level in the OGC group (8.9% vs. 14.4%; p = 0.046), but not in the non-OGC group (22.3% vs. 23.2%, p = 0.850). Multiple logistic regression models showed that the risk for obstructive CAD was lower in patients with a high HDL-C level than in those with a low HDL-C level in the OGC group (odds ratio: 0.584, 95% confidence interval: 0.343-0.995; p = 0.048), but not in the non-OGC group. In conclusion, it may be necessary to maintain a high HDL-C level to reduce the risk of obstructive CAD in asymptomatic diabetics after OGC is achieved.

Long-Term Survival Following Multivessel Revascularization in Patients With Diabetes: The FREEDOM Follow-On Study

BACKGROUND

The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial demonstrated that for patients with diabetes mellitus (DM) and multivessel coronary disease (MVD), coronary artery bypass grafting (CABG) is superior to percutaneous coronary intervention with drug-eluting stents (PCI-DES) in reducing the rate of major adverse cardiovascular and cerebrovascular events after a median follow-up of 3.8 years. It is not known, however, whether CABG confers a survival benefit after an extended follow-up period.

OBJECTIVES

The purpose of this study was to evaluate the long-term survival of DM patients with MVD undergoing coronary revascularization in the FREEDOM trial.

METHODS

The FREEDOM trial randomized 1,900 patients with DM and MVD to undergo either PCI with sirolimus-eluting or paclitaxel-eluting stents or CABG on a background of optimal medical therapy. After completion of the trial, enrolling centers and patients were invited to participate in the FREEDOM Follow-On study. Survival was evaluated using Kaplan-Meier analysis, and Cox proportional hazards models were used for subgroup and multivariate analyses.

RESULTS

A total of 25 centers (of 140 original centers) agreed to participate in the FREEDOM Follow-On study and contributed a total of 943 patients (49.6% of the original cohort) with a median follow-up of 7.5 years (range 0 to 13.2 years). Of the 1,900 patients, there were 314 deaths during the entire follow-up period (204 deaths in the original trial and 110 deaths in the FREEDOM Follow-On). The all-cause mortality rate was significantly higher in the PCI-DES group than in the CABG group (24.3% [159 deaths] vs. 18.3% [112 deaths]; hazard ratio: 1.36; 95% confidence interval: 1.07 to 1.74; p = 0.01). Of the 943 patients with extended follow-up, the all-cause mortality rate was 23.7% (99 deaths) in the PCI-DES group and 18.7% (72 deaths) in the CABG group (hazard ratio: 1.32; 95% confidence interval: 0.97 to 1.78; p = 0.076).

CONCLUSIONS

In patients with DM and MVD, coronary revascularization with CABG leads to lower all-cause mortality than with PCI-DES in long-term follow-up. (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450).

Comparative determinants of 5-year cardiovascular event rates in patients with unprotected left main coronary artery disease

BACKGROUND

Diabetes mellitus (DM), low ejection fraction (EF), and the extent of coronary artery disease (CAD) have all been identified as predictors of cardiovascular events in multivessel disease, but their comparative contributions to future risk remain unclear in patients with unprotected left main coronary artery (ULMCA) disease. Through this study we aimed to categorize the risk for cardiovascular events in patients with ULMCA disease using simple clinical descriptors.

PATIENTS AND METHODS

Our study included a total of 5975 patients with ULMCA disease from the Interventional Research Incorporation Society-Left MAIN Revascularization registry who were treated with percutaneous coronary intervention (n=2850), coronary artery bypass grafting (n=2337), or medical therapy alone (n=608). We categorized the risk for cardiovascular events using simple clinical descriptors (DM, low EF, and the extent of CAD). The primary outcome was a major adverse cardiac or cerebrovascular event (MACCE) (i.e. death from any cause, stroke, myocardial infarction, or repeat revascularization).

RESULTS

Overall, the 5-year rate of MACCE was highest in the medical group, lower in the percutaneous coronary intervention group, and lowest in the coronary artery bypass grafting group (42.5, 25.7, and 19.9%, respectively; P<0.001). In multivariable modeling, the presence of DM [hazard ratio (HR): 1.25; 95% confidence interval (CI): 1.12-1.40; P<0.001], low EF of 40% or less (HR: 1.83; 95% CI: 1.56-2.15; P<0.001), and the extent of CAD (HR: 1.14; 95% CI: 1.08-1.21; P<0.001) were independent predictors of MACCE; in addition, these factors were consistently associated with a significantly higher risk for MACCE, regardless of index treatment strategies.

CONCLUSION

Simple clinical descriptors can assist clinicians in identifying high-risk patients and in predicting future cardiovascular events within the broad range of risk factors for ULMCA disease.

Impact of type 2 diabetes mellitus on the long-term mortality in patients who were treated by coronary artery bypass surgery: A systematic review and meta-analysis

BACKGROUND

Recent scientific reports have mainly focused on the comparison between coronary artery bypass surgery (CABG) and percutaneous coronary intervention. However, the impact of type 2 diabetes mellitus (T2DM) on mortality in patients who were treated by CABG was often ignored. Therefore, we aimed to compare the long-term mortality following CABG in patients with and without T2DM.

METHODS

Studies comparing the long-term adverse outcomes following CABG in patients with and without T2DM were searched from electronic databases. Total number of deaths (primary outcome) and events of myocardial infarction (MI), major adverse cerebrovascular and cardiovascular events (MACCEs), stroke, and repeated revascularization (secondary outcomes) were carefully extracted. An analysis was carried out whereby odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the RevMan 5.3 software.

RESULTS

Eleven studies with a total number of 12,965 patients were included. Current results showed that mortality was significantly higher in patients with T2DM with OR: 1.54, 95% CI: 1.37 to 1.72, P < .00001; OR: 1.53, 95% CI: 1.36 to 1.72, P < .00001; and OR: 1.53, 95% CI: 1.26 to 1.87, P < .0001 at 1 to 15, 5 to 15, and 7 to 15 years, respectively. However, MI, repeated revascularization, MACCEs, and stroke were not significantly different with OR: 1.15, 95% CI: 0.81 to 1.64, P = .44; OR: 1.09, 95% CI: 0.88 to 1.36, P = .43; OR: 1.11, 95% CI: 0.83 to 1.48, P = .48; and OR: 1.69, 95% CI: 0.93 to 3.07, P = .08, respectively.

CONCLUSION

Following CABG, a significantly higher rate of mortality was continually observed in patients with T2DM compared to patients without T2DM showing that the former apparently has a high impact on the long-term mortality. However, even if T2DM is an independent risk factor for mortality, it should not be ignored that CABG remains the best revascularization strategy in these patients.

Off-pump versus on-pump coronary artery bypass grafting in patients with diabetes: a meta-analysis

AIMS

The effects of off-pump CABG (OFF-CABG) versus on-pump CABG (ON-CABG) in diabetic patients remain controversial. The aim of our study was to compare mortality and postoperative morbidity between OFF-CABG and ON-CABG for diabetic patients.

METHODS

Electronic databases including PubMed, EMBASE and Cochrane Library for studies investigating clinical outcomes of OFF-CABG versus ON-CABG in diabetic patients were searched, collecting data from inception until June 2016. We pooled the odds ratios from individual studies and performed heterogeneity, quality assessment and publication bias analysis.

RESULTS

A total of 543,220 diabetic patients in 10 studies were included. The overall mortality (OR, 0.87; 95% CI, 0.58-1.31; p = 0.50) was comparable between the OFF-CABG and ON-CABG. OFF-CABG was associated with significantly fewer cerebrovascular accidents (OR, 0.45; 95% CI, 0.31-0.65; p < 0.0001), bleeding complications (OR, 0.59; 95% CI, 0.43-0.80; p < 0.001) and pulmonary complications. However, no differences in myocardial infarction (OR, 0.76; 95% CI, 0.52-1.12; p = 0.16), renal failure (OR, 0.74; 95% CI, 0.50-1.11; p = 0.14) and other postoperative morbidity outcomes were found.

CONCLUSIONS

OFF-CABG significantly reduces the incidence of postoperative cerebrovascular accidents and bleeding complications compared with ON-CABG in diabetic patients. No differences were found regarding mortality, myocardial infarction and renal failure between these two techniques. Our study suggests that OFF-CABG may be an optimal strategy for diabetic patients although adequately powered randomized trials are needed to further verify the finding.

Indications, algorithms, and outcomes for coronary artery bypass surgery in patients with acute coronary syndromes

For patients with a non-ST-segment elevation acute coronary syndrome (NSTE-ACS), guideline recommendations and treatment pathways focus on revascularization for definitive treatment if the patient is an appropriate candidate. Despite the widespread use of revascularization for NSTE-ACS, most patients undergo a percutaneous coronary intervention, whereas a minority of patients undergo coronary artery bypass grafting. Focusing specifically on the USA, the contemporary utilization, preoperative and perioperative considerations, and outcomes of NSTE-ACS patients undergoing coronary artery bypass grafting have not been comprehensively reviewed.

Myocardial Revascularization for Patients With Diabetes: Coronary Artery Bypass Grafting or Percutaneous Coronary Intervention?

Patients affected by diabetes usually have extensive coronary artery disease. Coronary revascularization has a prominent role in the treatment of coronary artery disease in the expanding diabetic population. However, diabetic patients undergoing coronary artery bypass grafting or percutaneous coronary intervention experience worse outcomes than nondiabetic patients. Several studies comparing coronary artery bypass grafting vs percutaneous coronary intervention in subgroups of diabetic patients demonstrated a survival advantage and fewer repeat revascularization procedures with an initial surgical strategy. This review summarizes the current state of evidence comparing the effectiveness and safety of coronary artery bypass grafting and percutaneous coronary intervention in diabetic patients.

Comparison of the Postprocedural Quality of Life between Coronary Artery Bypass Graft Surgery and Percutaneous Coronary Intervention: A Systematic Review

The treatment of choice between coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) has remained unclear. Considering quality of life (QOL) increases life expectancy, we believe QOL should be important in determining the optimum treatment. Thus the objective of this review was to illustrate the comparative effects of CABG and PCI on postprocedural QOL. Methods. We searched PubMed (Medline) and Embase from inception of the databases to May 2014 using "PCI versus CABG quality of life", "Percutaneous Coronary intervention versus Coronary artery bypass graft surgery Quality of life", "PCI versus CABG health status", "Angioplasty versus CABG", "Percutaneous coronary intervention versus coronary artery bypass surgery health status", and different combinations of the above terms. 447 articles were found. After applying strict exclusion criteria, we included 13 studies in this review. Results. From the 9 studies that compared QOL scores at 6 months after procedure, 5 studies reported CABG to be superior. From the 10 studies that compared QOL among patients at 1 year after procedure, 9 reported CABG to be superior. Conclusion. It can be established that CABG is superior to PCI in improving patient's QOL with respect to all scales used to determine quality of life.

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.

Evaluation of the predictive value of coronary artery calcium score for obstructive coronary artery disease in asymptomatic Korean patients with type 2 diabetes mellitus

BACKGROUND

Compared with coronary computed tomographic angiography (CCTA), the coronary artery calcium score (CACS) may be limited in predicting adverse cardiovascular events in asymptomatic diabetic patients.

METHODS

We evaluated the predictive value of CACS for obstructive coronary plaques (OCPs) assessed by CCTA in 328 consecutive asymptomatic patients with type 2 diabetes mellitus who had an estimated glomerular filtration rate greater than 60 ml/min/1.73 m².

RESULTS

In total, 29 (9%) patients had OCPs: calcified or mixed OCPs and noncalcified OCPs were found in 26 (8%) and three (1%) patients, respectively. On the basis of a CACS of 0, 1-10, 11-100, and greater than 100, OCPs were found in 2, 5, 15, and 36% of patients, respectively. On receiver operating characteristic curve analysis, the optimal cutoff CACS for predicting OCPs was found to be 33, with 83% sensitivity and 81% specificity (area under the curve, 0.853; 95% confidence interval, 0.777-0.930; P<0.001). Positive and negative predictive values of a CACS of 33 for OCPs were 30 and 98%, respectively. On multivariate logistic regression analysis, age [odds ratio (OR), 1.09], microalbuminuria (OR, 3.43), current smoking (OR, 3.93), and CACS greater than 33 (OR, 15.85) were found to be independently associated with an increased risk for OCPs (P<0.05, respectively). The predictive significance of CACS greater than 33 for OCPs improved after considering the status of microalbuminuria and current smoking.

CONCLUSION

These findings suggest that CACS is an effective gatekeeper for evaluating obstructive coronary artery disease using CCTA in asymptomatic Korean patients with type 2 diabetes mellitus who have near-normal kidney function.

Long-term clinical and angiographic outcomes in patients with diabetes undergoing coronary artery bypass graft surgery: results from the Project of Ex-vivo Vein Graft Engineering via Transfection IV trial

BACKGROUND

There is limited information about the association between diabetes, its treatment, and long-term angiographic and clinical outcomes in patients undergoing coronary artery bypass graft surgery (CABG). We evaluated the association of diabetes and its treatment with 1-year angiographic graft failure and 5-year clinical outcomes in patients undergoing CABG.

METHODS

Using data from 3,014 patients in PREVENT IV, we analyzed angiographic and clinical outcomes in patients with and without diabetes and among those who did and did not receive insulin before CABG. Logistic regression and Cox proportional hazards models were used to adjust for differences in baseline variables.

RESULTS

Overall, 1,139 (37.8%) patients had diabetes. Of these, 305 (26.8%) received insulin. One-year rates of vein graft failure were similar in patients with and without diabetes but, among diabetics, tended to be higher in patients who received insulin compared with those who did not. At 5 years, rates of death, myocardial infarction, or revascularization were higher among patients with compared with those without diabetes (adjusted hazard ratio 1.57; 95% CI 1.26-1.96; P < .001) and, among diabetics, higher among those who received insulin (adjusted hazard ratio 1.15; 95% CI 1.02-1.30; P = .02).

CONCLUSIONS

Patients with diabetes had similar rates of vein graft failure but worse clinical outcomes than patients without diabetes. Patients who received insulin had significantly worse clinical outcomes than patients who did not receive insulin. Further studies to better understand the mechanism behind these findings and to improve the outcomes of patients with insulin-requiring diabetes undergoing CABG surgery are warranted.

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.

Lessons learned from the use of 1,977 in-situ bilateral internal mammary arteries: a retrospective study

Background

We sought to determine the early and long-term results of in-situ bilateral internal mammary artery (BIMA) grafting in patients undergoing coronary artery bypass graft surgery (CABG).

Methods

Between 1992 and 2011, 16,364 patients underwent primary isolated CABG involving at least one in-situ IMA at our institution. Among these, 1,977 patients underwent in-situ BIMA grafting: the right IMA was used to revascularize the right coronary artery system in 1,279, the circumflex system in 454 patients, and the left anterior descending (LAD) in 244. Logistic and Cox regression analyses were used to predict in-hospital mortality and cumulative late death.

Results

Late survival among BIMA patients was negatively and independently influenced by chronic obstructive pulmonary disease (hazard ratio (HR) 2.4, 95% confidence interval (CI) 1.6-3.4, p = 0.0005), age (HR 1.2, 95% CI 1.1-1.3, p < 0.001), and mediastinitis (HR 2.1, 95% CI 1.1-4.2, p < 0.03). Gender, body mass index, diabetes, choice of target for the second (non-LAD) IMA, and conduit grafted to the LAD (RIMA vs. LIMA) did not influence late survival among BIMA patients. A BIMA grafting strategy was significantly beneficial for younger patients. However, it was not associated with superior late survival for patients aged 66 years and above at the time of CABG, and showed a trend to harm among octogenarians (HR 1.05, 95% CI 0.70-1.56, p = 0.80).

Conclusions

Female gender, non-insulin dependent diabetes, and the site of second IMA anastomosis did not influence early and long-term outcomes in patients undergoing CABG with in-situ BIMA grafting. The right and left IMAs are equally effective conduits for the LAD. However, advanced age, chronic obstructive pulmonary disease, and insulin-treated diabetes mellitus have a negative impact on late survival among patients with BIMA grafts.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-014-0158-9) contains supplementary material, which is available to authorized users.

Bilateral internal thoracic artery grafting in insulin-treated diabetes

BACKGROUND

We sought to assess the risk and late outcome of bilateral internal thoracic artery grafting in eligible insulin-treated diabetic subsets.

METHODS

147 insulin-treated diabetic patients undergoing arterial revascularization were grouped as: skeletonized bilateral internal thoracic artery (n = 83) or internal thoracic artery-radial artery (n = 64). Chronic lung disease or overweight and female constituted exclusion criteria for bilateral internal thoracic artery grafts.

RESULTS

Patients who had bilateral internal thoracic artery grafts were younger and comprised fewer females. Left-sided bilateral internal thoracic artery configurations were predominantly applied. Despite mean hemoglobin A1c of 8.0% ± 1% (range, 7%-13.5%) respective rates of deep sternal infection in bilateral internal thoracic artery and radial artery patients were 1.2% and 0%; superficial wound infection occurred in 3.1% and 3.6%, respectively. One sternoplasty was performed. Bilateral internal thoracic artery grafting did not correlate with sternal complications (odds ratio = 2.24, 95%CI: 0.56-8.95, p = 0.256). Of the radial artery conduits, 98% were adequate, and procurement-site complications occurred in 3.1%. Follow-up was 2-58 months (median, 25 months). Five-year survival was comparable in the 2 groups (p = 0.360). Bilateral internal thoracic artery grafting did not reduce late major adverse cardiac events (p = 0.729) or late mortality (p = 0.384).

CONCLUSIONS

Skeletonized bilateral internal thoracic artery grafts can be used with acceptable risk in a substantial portion of insulin-treated diabetic patients, so it should not be automatically denied, but the choice of such grafts is not associated with midterm cardiac benefits.

Sirolimus-eluting stent versus bare metal stent in diabetic patients: the final five-year follow-up of the DIABETES trial

AIMS

The DIABETES (DIABETes and sirolimus-Eluting Stent) trial is a prospective, multicentre, randomised, controlled trial aimed at demonstrating the efficacy of sirolimus-eluting stent (SES) as compared to bare metal stent (BMS) implantation in diabetic patients. The aim of the present analysis was to assess the five-year clinical follow-up of the patients included in this trial.

METHODS AND RESULTS

One hundred and sixty patients (222 lesions) were included: 80 patients were randomised to SES and 80 patients to BMS. Patients were eligible for the study if they were identified as non-insulin-dependent diabetics (NIDDM) or insulin-dependent diabetics (IDDM), with significant native coronary stenoses in ≥1 vessel. There was a sub-randomisation according to diabetes status. Clinical follow-up was extended up to five years. Five-year clinical follow-up was obtained in 96.2%. Overall, MACE at five years was significantly lower in the SES group as compared with the BMS arm, mainly due to a significant reduction in TLR. There were no significant differences in cardiac death or myocardial infarction (MI). This was also observed in both prespecified subgroups IDDM and NIDDM. In the SES group, the incidence density of definite/probable stent thrombosis was 0.53 per 100 person-years, whereas in the BMS group it was 0.8 per 100 person-years. Independent predictors of MACE were: SES implantation (p<0.001), multivessel stent implantation (p=0.04), and creatinine levels (p=0.001).

CONCLUSIONS

Five-year follow-up of the DIABETES trial suggests the effect of SES in reducing TLR is similar in both IDDM and NIDDM. No major safety concerns in terms of ST, MI or mortality were observed.

Ischemic mitral regurgitation: pathophysiology, diagnosis and surgical treatment

Ischemic mitral valve regurgitation often complicates acute myocardial infarction and also represents a negative prognostic factor for long-term survival in patients undergoing surgical myocardial revascularization. While severe mitral regurgitation should always be corrected during a coronary artery bypass operation, the decision making is more difficult in patients with a mild-to-moderate degree of regurgitation. Recent studies and experimental protocols have elucidated the pathophysiological mechanisms leading to mitral regurgitation with great interest in annular modifications and subvalvular alterations. These data suggest that new and integrated surgical approaches that address annuloplasty ring sizing, ring type selection and tethering phenomenon (i.e., chordal cutting, 'edge-to-edge' technique and left-ventricular plasty techniques) are required for a safer and durable valve repair. Transthoracic and transesophageal echocardiography are useful in determining the etiology and the degree of mitral regurgitation, to assess mitral deformation and to measure indexes of global and regional left-ventricular remodeling. Stress echocardiography may unmask higher degrees of mitral regurgitation. More data are needed in order to confirm the promising and interesting preliminary experimental findings of magnetic resonance imaging in diagnosis and clinical evaluation of ischemic mitral regurgitation.

Role of surgical revascularization in diabetic patients with coronary artery disease

Diabetes is a well-known risk factor for morbidity and mortality associated with coronary artery disease. Currently, diabetics represent approximately a quarter of patients requiring coronary revascularization in the USA. The purpose of this article is to review and analyze the available data in surgical revascularization of diabetic patients with coronary artery disease. The review will also examine new developments in myocardial revascularization and assess their probable impact on the long-term outcome of diabetic patients.

Can cardiac computed tomography predict cardiovascular events in asymptomatic type-2 diabetics?: results of a long term follow-up

Background

Doubts remain about atherosclerotic disease and risk stratification of asymptomatic type-2 diabetic patients (T2DP). This study aims to evaluate the usefulness of calcium score (CS) and coronary computed tomography (CT) angiography (CTA) to predict fatal and non fatal cardiovascular events (CVEV) in T2DP.

Methods

Eighty-five consecutive T2DP undergoing CT (Phillips Brilliance, 16-slice) with CS and CTA were prospectively enrolled in a transversal case-control study. Patients were followed for 48 months (range 18 - 68) to assess CVEV: cardiovascular death, acute coronary syndrome, revascularisation and stroke. Potential predictors of CVEV were identified. Predictive models based on clinical features, CTA and CS were created and compared.

Results

Performing CT impacted T2DP treatment. Cardiovascular risk was lowered during follow-up but metabolic control remained suboptimal. CVEV occurred in 11.8% T2DP (3.1%/year). CS ≥86.6 was predictor of CVEV over time, with a high negative predictive value, an 80% sensitivity and 74.7% specificity. Although its prognostic value was not independent of the presence/absence of obstructive CAD, adding CS and CTA data to clinical parameters improved the prediction of CVEV: the combined model had the highest AUC (0.888, 95%CI 0.789-0.987, p < 0.001) for the prediction of the study endpoints.

Conclusions

CS showed great value in T2DP risk stratification and its prognostic value was further enhanced by CTA data. Information provided by CT may help predict CVEV in T2DP and potentially improve their outcome.

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.

CARBOHYDRATE METABOLISM DISORDERS AND CORONARY HEART DISEASE: PROGNOSTIC VALUE AND REVASCULARISATION EFFECTIVENESS

This literature review presents the data on the prevalence and prognostic value of carbohydrate metabolism disorders, such as Type 2 diabetes mellitus (DM) and pre-diabetes — fasting hyperglycaemia and impaired glucose tolerance), among patients with coronary heart disease (CHD). The authors present the results of large studies on comparative effectiveness of modern pharmacological treatment and myocardial revascularisation (percutaneous coronary intervention and coronary artery bypass graft surgery) in patients with CHD and DM. 

Percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in the treatment of diabetic patients with multi-vessel coronary disease: a meta-analysis

Diabetes is prevalent in patients with coronary artery disease. In diabetic patients with multi-vessel coronary disease, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are widely used for revascularization. We aimed to compare the effectiveness and safety of PCI and CABG in these patients. Nine randomized controlled trials were identified in which a total of 1047 diabetic patients were randomly assigned to PCI and 1054 to CABG. Results showed that five-year mortality was significantly higher in diabetic patients after PCI than after CABG (risk difference (RD) of 7%; P<0.001); repeated revascularization was more common after PCI than after CABG (one-year RD of 13%; P<0.001); major adverse cardiac and cerebrovascular events were also more frequent after PCI (one-year RD of 12%; P<0.001); however, the cerebrovascular accident rate was lower in the PCI group than the CABG group (one-year RD of -2%; P=0.004). Conclusively, in diabetic patients with multi-vessel coronary disease, CABG was not only more effective than PCI in reducing mortality but also led to fewer repeated revascularizations and fewer major adverse cardiac and cerebrovascular events. Despite these benefits, CABG did put diabetic patients at higher risk for cerebrovascular accident than PCI.

Revascularization for left main and multivessel coronary artery disease in the drug-eluting stent era: integration of recent drug-eluting stent trials

As older patients comprise a greater proportion of the population, the incidence of multivessel and left main coronary artery disease is increasing. Given the improvements in percutaneous coronary intervention, more patients are suitable for this revascularization strategy. However, the optimal revascularization strategy remains a moving target. Numerous trials, extending from the bypass surgery versus medical therapy era to the most current drug-eluting stent versus bypass surgery era, provide information to select the most appropriate revascularization strategy. The objective of this review is to summarize these data.

Comparative effectiveness of revascularization strategies

BACKGROUND

Questions persist concerning the comparative effectiveness of percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG). The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) collaborated to compare the rates of long-term survival after PCI and CABG.

METHODS

We linked the ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008. Outcomes were compared with the use of propensity scores and inverse-probability-weighting adjustment to reduce treatment-selection bias.

RESULTS

Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results were noted in multiple subgroups and with the use of several different analytic methods. Residual confounding was assessed by means of a sensitivity analysis.

CONCLUSIONS

In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI. (Funded by the National Heart, Lung, and Blood Institute.).

Myocardial ischemia: a silent epidemic in Type 2 diabetes patients

The prevalence of diabetes mellitus is increasing consistently. Coronary artery disease (CAD) is the main cause of death; however, silent myocardial ischemia (SMI) is more frequent in diabetic patients. Early CAD diagnosis provided by SMI screening could lead to decreased cardiovascular complications and mortality. Current guidelines recommend screening for SMI in asymptomatic diabetic patients selected on a basis of high cardiovascular risk, followed by coronary angiogram in case of a positive stress test. However, the benefit of systematic SMI screening has not been demonstrated in diabetic patients with optimal treatment of risk factors. The benefit of revascularization in diabetic patients with SMI seems to be restricted to patients with severe CAD. Prospective studies are required to identify diabetic patients who may potentially benefit from SMI screening. These patients should have a high prevalence of severe CAD and potential benefit of revascularization, such as patients with renal failure, left ventricular dysfunction and peripheral or carotid occlusive arterial disease.

Outcome of diabetic and non-diabetic patients undergoing successful percutaneous coronary intervention of chronic total occlusion

INTRODUCTION

Diabetes mellitus is associated with an increased risk of adverse clinical outcomes after percutaneous coronary intervention (PCI). The prognosis of patients with diabetes mellitus and chronic total occlusion (CTO) treated with PCI is poorly investigated. Current study evaluates outcome of successful PCI on CTO in patients with and without diabetes.

METHODS

One hundred and sixty three patients treated with successful PCI on CTO between January 2009 and March 2011 were prospectively identified from the PCI registry at the Madani Heart Center, Tabriz, Iran. Patients were followed for 15±3 months, were evaluated for the occurrence of major adverse cardiac events (MACE) comprising death, acute myocardial infarction, and need for repeat revascularization.

RESULTS

No differences were found in baseline clinical and procedural variables between patients with (n=34) and without diabetes (n=129), unless for hypertension (p=0.03). Hospitalization period after PCI in diabetics (3.26±0.61 days) and non-diabetics (2.86±0.52 days) was similar. In-hospital MACE occurred in 8 (23.5%) individuals of diabetics and 10 (7.8%) individuals of non-diabetics (p=0.02), among them revascularization was significantly higher in diabetics (20.6% vs. 7%, p=0.04). Follow-up events in diabetic and non-diabetic groups were 12 (35.3%) and 37 (28.5%), respectively (p was not significant).

CONCLUSION

In patients undergoing successful PCI on CTO, diabetes is associated with higher in-hospital adverse events; however diabetes does not affect long term outcomes in these patients.