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

Prognostic value of the stress-hyperglycaemia ratio in patients with moderate-to-severe coronary artery calcification: Insights from a large cohort study

AIM

To evaluate the relationship between the stress-hyperglycaemia ratio (SHR) and the clinical prognosis of patients with moderate-to-severe coronary artery calcification (MSCAC).

METHODS

We consecutively enrolled 3841 patients with angiography-detected MSCAC. The individuals were categorized into three groups based on SHR tertiles: T1 (SHR ≤ 0.77), T2 (0.77 < SHR ≤ 0.89) and T3 (SHR > 0.89). The SHR value was calculated using the formula SHR = [admission glucose (mmol/L)]/[1.59 × HbA1c (%) - 2.59]. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCEs), including all-cause death, non-fatal myocardial infarction and non-fatal stroke.

RESULTS

During a median follow-up of 3.11 years, 241 MACCEs were recorded. Kaplan-Meier survival analysis showed that the SHR T3 group had the highest incidence of MACCEs (P < .001). Moreover, findings from the restricted cubic spline analysis showed a significant and positive association between the SHR and MACCEs. This correlation remained consistent even after considering other variables that could potentially impact the results (Pnon-linear = .794). When comparing SHR T1 with SHR T3, it was found that SHR T3 was significantly associated with an increased risk of the primary outcome (adjusted hazard ratio = 1.50; 95% confidence interval: 1.10-2.03).

CONCLUSIONS

Patients with MSCAC showed a positive correlation between the SHR and MACCE rate over a 3-year follow-up period. The study showed that an SHR value of 0.83 is the key threshold, indicating a poor prognosis. Future large-scale multicentre investigations should be conducted to determine the predictive value of the SHR in patients with MSCAC.

Lipid-lowering in diabetes: An update

Atherosclerotic cardiovascular disease (ASCVD) is accelerated in people with diabetes. Dyslipidemia, hyperglycemia, oxidative stress, and inflammation play a role via a variety of mechanisms operative in the artery wall. In addition, some unique features predispose people with type 1 diabetes to accelerated atherosclerosis. Various organizations have created guidelines that provide advice regarding screening, risk assessment, and roadmaps for treatment to prevent ASCVD in diabetes. Management of dyslipidemia, especially with statins, has proven to be of immense benefit in the prevention of clinical CVD. However, since many patients fail to attain the low levels of low-density lipoproteins (LDL) recommended in these guidelines, supplemental therapy, such as the addition of ezetimibe, bempedoic acid or PCSK9 inhibitors, is often required to reach LDL goals. As a result, the upfront use of combination therapies, particularly a statin plus ezetimibe, is a rational initial approach. The addition to statins of drugs that specifically lower triglyceride levels has not proven beneficial, although the addition of icosapent-ethyl has been shown to be of value, likely by mechanisms independent of triglyceride lowering. Newer treatments in development, including apoC-III and ANGPTL3 inhibitors, seem promising in further reducing apoB-containing lipoproteins.

Intravascular Imaging and Angiography Guidance in Complex Percutaneous Coronary Intervention Among Patients With Diabetes: A Secondary Analysis of a Randomized Clinical Trial

Importance

Data are limited regarding the effects of intravascular imaging guidance during complex percutaneous coronary intervention (PCI) in patients with diabetes.

Objective

To compare the clinical outcomes of intravascular imaging-guided vs angiography-guided complex PCI in patients with or without diabetes.

Design, Setting, and Participants

This prespecified secondary analysis of a subgroup of patients in RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention), an investigator-initiated, open-label multicenter trial, analyzed enrolled patients who underwent complex PCI at 20 sites in Korea from May 2018 through May 2021. Eligible patients were randomly assigned in a 2:1 ratio to undergo either the intravascular imaging-guided PCI or angiography-guided PCI. Data analyses were performed from June 2023 to April 2024.

Interventions

Percutaneous coronary intervention was performed either under the guidance of intravascular imaging or angiography alone.

Main Outcomes and Measures

The primary end point was target vessel failure (TVF), defined as a composite of cardiac death, target vessel-related myocardial infarction, or target vessel revascularization.

Results

Among the 1639 patients included in the analysis (mean [SD] age, 65.6 [10.2] years; 1300 males [79.3%]), 617 (37.6%) had diabetes. The incidence of TVF was significantly higher in patients with diabetes than patients without diabetes (hazard ratio [HR], 1.86; 95% CI, 1.33-2.60; P < .001). Among patients without diabetes, the intravascular imaging-guided PCI group had a significantly lower incidence of TVF compared with the angiography-guided PCI group (4.7% vs 12.2%; HR, 0.41 [95% CI, 0.25-0.67]; P < .001). Conversely, in patients with diabetes, the risk of TVF was not significantly different between the 2 groups (12.9% vs 12.3%; HR, 0.97 [95% CI, 0.60-1.57]; P = .90). There was a significant interaction between the use of intravascular imaging and diabetes for the risk of TVF (P for interaction = .02). Among patients with diabetes, only those with good glycemic control (hemoglobin A1c level ≤7.5%) and who achieved stent optimization by intravascular imaging showed a lower risk of future ischemic events (HR, 0.31; 95% CI, 0.12-0.82; P = .02).

Conclusions and Relevance

In this secondary analysis of a subgroup of patients in the RENOVATE-COMPLEX-PCI trial, intravascular imaging guidance reduced the risk of TVF compared with angiography guidance in patients without diabetes (but not in patients with diabetes) during complex PCI. In patients with diabetes undergoing complex PCI, attention should be paid to stent optimization using intravascular imaging and glycemic control to improve outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT03381872.

High stress hyperglycemia ratio predicts adverse clinical outcome in patients with coronary three-vessel disease: a large-scale cohort study

BACKGROUND

Coronary three-vessel disease (CTVD) accounts for one-third of the overall incidence of coronary artery disease, with heightened mortality rates compared to single-vessel lesions, including common trunk lesions. Dysregulated glucose metabolism exacerbates atherosclerosis and increases cardiovascular risk. The stress hyperglycemia ratio (SHR) is proposed as an indicator of glucose metabolism status but its association with cardiovascular outcomes in CTVD patients undergoing percutaneous coronary intervention (PCI) remains unclear.

METHODS

10,532 CTVD patients undergoing PCI were consecutively enrolled. SHR was calculated using the formula: admission blood glucose (mmol/L)/[1.59×HbA1c (%)-2.59]. Patients were divided into two groups (SHR Low and SHR High) according to the optimal cutoff value of SHR. Multivariable Cox regression models were used to assess the relationship between SHR and long-term prognosis. The primary endpoint was cardiovascular (CV) events, composing of cardiac death and non-fatal myocardial infarction (MI).

RESULTS

During the median follow-up time of 3 years, a total of 279 cases (2.6%) of CV events were recorded. Multivariable Cox analyses showed that high SHR was associated with a significantly higher risk of CV events [Hazard Ratio (HR) 1.99, 95% Confidence interval (CI) 1.58-2.52, P < 0.001). This association remained consistent in patients with (HR 1.50, 95% CI 1.08-2.10, P = 0.016) and without diabetes (HR 1.97, 95% CI 1.42-2.72, P < 0.001). Additionally, adding SHR to the base model of traditional risk factors led to a significant improvement in the C-index, net reclassification and integrated discrimination.

CONCLUSIONS

SHR was a significant predictor for adverse CV outcomes in CTVD patients with or without diabetes, which suggested that it could aid in the risk stratification in this particular population regardless of glucose metabolism status.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Left Main Disease With and Without Diabetes: Findings From a Pooled Analysis of 4 Randomized Clinical Trials

BACKGROUND

Diabetes may be associated with differential outcomes in patients undergoing left main coronary revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The aim of this study was to investigate outcomes in patients with left main disease with and without diabetes randomized to PCI versus CABG.

METHODS

Individual patient data were pooled from 4 trials (SYNTAX [Synergy Between PCI With Taxus and Cardiac Surgery], PRECOMBAT [Premier of Randomized Comparison of Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease], NOBLE [Nordic-Baltic-British Left Main Revascularisation Study], and EXCEL [Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization]) that randomized patients with left main disease to PCI or CABG. Patients were considered suitable for either approach. Patients were categorized by diabetes status. Kaplan-Meier event rates, Cox model hazard ratios, and interactions were assessed.

RESULTS

Among 4393 patients, 1104 (25.1%) had diabetes. Patients with diabetes experienced higher rates of 5-year death (158/1104 [Kaplan-Meier rate, 14.7%] versus 297/3289 [9.3%]; P<0.001), spontaneous myocardial infarction (MI; 67/1104 [6.7%] versus 114/3289 [3.7%]; P<0.001), and repeat revascularization (189/1104 [18.5%] versus 410/3289 [13.2%]; P<0.001). Rates of all-cause mortality did not differ after PCI versus CABG in those with (84/563 [15.3%] versus 74/541 [14.1%]; hazard ratio, 1.11 [95% CI, 0.82-1.52]) or without (155/1634 [9.7%] versus 142/1655 [8.9%]; hazard ratio, 1.08 [95% CI, 0.86-1.36; PintHR=0.87) diabetes. Rates of stroke within 1 year were lower with PCI versus CABG in the entire population, with no heterogeneity based on diabetes status (PintHR=0.51). The 5-year rates of spontaneous MI and repeat coronary revascularization were higher after PCI regardless of diabetes status (spontaneous MI: 45/563 [8.9%] versus 22/541 [4.4%] in diabetes and 82/1634 [5.3%] versus 32/1655 [2.1%] in no diabetes, PintHR=0.47; repeat revascularization: 127/563 [24.5%] versus 62/541 [12.4%] in diabetes and 254/1634 [16.3%] versus 156/1655 [10.1%] in no diabetes, PintHR=0.18). For spontaneous MI and repeat revascularization, there were greater absolute risk differences beyond 1 year in patients with diabetes (4.9% and 9.9%) compared with those without (2.1% and 4.3%; PintARD=0.047 and 0.016).

CONCLUSIONS

In patients with left main disease considered equally suitable for PCI or CABG and with largely low to intermediate SYNTAX scores, diabetes was associated with higher rates of death and cardiovascular events through 5 years. Compared with CABG, PCI resulted in no difference in the risk of death and a lower risk of early stroke regardless of diabetes status, and a higher risk of spontaneous MI and repeat coronary revascularization, with larger late absolute excess risks in patients with diabetes.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01205776, NCT0146651, NCT00422968, and NCT00114972.

Prognostic Impact of Drug-Coated Balloons in Patients With Diabetes Mellitus: A Propensity-Matched Study

Patients with diabetes mellitus (DM) are at higher risk of restenosis and stent thrombosis after percutaneous coronary intervention (PCI) and drug-eluting stent (DES) positioning. Whether drug-coated balloons (DCB) can offer any benefit in this subset of patients has been seldom cleared out and was the aim of the present propensity-matched cohort study, that compared the prognostic impact of DCB versus DES in patients with DM who underwent PCI. Patients with DM enrolled in the NOvara-BIella-TREnto (NOBITRE) Registry were identified and matched according to propensity score, to a control population of patients with DM treated with DES. The primary study end point was the occurrence of major adverse cardiovascular events (MACEs). A total of 150 patients were identified in the DCB group and matched with 150 DES-treated patients. Patients treated with DCB displayed more often a previous cardiovascular history and received a more complete pharmacological therapy. Target vessel diameter and the percentage of stenosis were lower in patients with DCB, whereas binary in-stent restenosis was more common (p <0.001, p = 0.003, and p <0.001, respectively). Paclitaxel-eluting balloon represented the most common strategy in the DCB group, whereas Zotarolimus-eluting stents were used in half of the DES population. At a median follow-up of 545.5 days, MACE occurred in 54 (19.4%) of patients, with no difference according to the PCI strategy (21.6% vs 17.3%, adjusted hazard ratio [95% confidence interval] 1.51 [0.46 to 4.93], p = 0.50). Major ischemic end points were slightly increased in patients treated with DCB, whereas overall death was significantly reduced (3.6% vs 10.9%; adjusted hazard ratio [95% confidence interval] 0.27 [0.08 to 0.91], p = 0.03). In conclusion, the present propensity-matched study shows that, in patients with DM who underwent PCI for in-stent restenosis or de novo lesions, the use of DCB is associated with a similar rate of MACE and a modest increase in target lesion failure, but a significantly improved survival as compared with DES.

Everolimus-Eluting Stents or Bypass Surgery for Multivessel Disease in Diabetics: The BEST Extended Follow-Up Study

BACKGROUND

Diabetes mellitus is associated with more complex coronary artery diseases. Coronary artery bypass grafting (CABG) is a preferred revascularization strategy over percutaneous coronary intervention (PCI) in diabetics with multivessel coronary artery disease (MVD).

OBJECTIVES

This study sought to examine the different prognostic effects of revascularization strategies according to the diabetes status from the randomized BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease) trial.

METHODS

Patients (n = 880) with MVD were randomly assigned to undergo PCI with an everolimus-eluting stent vs CABG stratified by diabetics (n = 363) and nondiabetics (n = 517). The primary endpoint was the composite of death, myocardial infarction, or target vessel revascularization during a median follow-up of 11.8 years (IQR: 10.6-12.5 years).

RESULTS

In diabetics, the primary endpoint rate was significantly higher in the PCI group than in the CABG group (43% and 32%; HR: 1.53; 95% CI: 1.12-2.08; P = 0.008). However, in nondiabetics, no significant difference was found between the groups (PCI group, 29%; CABG group, 29%; HR: 0.97; 95% CI: 0.67-1.39; P = 0.86; Pinteraction= 0.009). Irrespective of the presence of diabetes, no significant between-group differences were found in the rate of a safety composite of death, myocardial infarction, or stroke and mortality rate. However, the rate of any repeat revascularization was significantly higher in the PCI group than in the CABG group.

CONCLUSIONS

In diabetics with MVD, CABG was associated with better clinical outcomes than PCI. However, the mortality rate was similar between PCI and CABG irrespective of diabetes status during an extended follow-up. (Ten-Year Outcomes of Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease [BEST Extended], NCT05125367; Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease [BEST], NCT00997828).

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Impact of Advanced Age on the Incidence of Major Adverse Cardiovascular Events in Patients with Type 2 Diabetes Mellitus and Stable Coronary Artery Disease in a Real-World Setting in Spain

Patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) without myocardial infarction (MI) or stroke are at high risk for major cardiovascular events (MACEs). We aimed to provide real-world data on age-related clinical characteristics, treatment management, and incidence of major cardiovascular outcomes in T2DM-CAD patients in Spain from 2014 to 2018. We used EHRead® technology, which is based on natural language processing and machine learning, to extract unstructured clinical information from electronic health records (EHRs) from 12 hospitals. Of the 4072 included patients, 30.9% were younger than 65 years (66.3% male), 34.2% were aged 65-75 years (66.4% male), and 34.8% were older than 75 years (54.3% male). These older patients were more likely to have hypertension (OR 2.85), angina (OR 1.64), heart valve disease (OR 2.13), or peripheral vascular disease (OR 2.38) than those aged <65 years (p < 0.001 for all comparisons). In general, they were also more likely to receive pharmacological and interventional treatments. Moreover, these patients had a significantly higher risk of MACEs (HR 1.29; p = 0.003) and ischemic stroke (HR 2.39; p < 0.001). In summary, patients with T2DM-CAD in routine clinical practice tend to be older, have more comorbidities, are more heavily treated, and have a higher risk of developing MACE than is commonly assumed from clinical trial data.

Utility of Preoperative N-Terminal Pro-B-Type Natriuretic Peptide in the Prognosis of Coronary Artery Bypass Grafting

Although N-terminal pro-B-type natriuretic peptide (NT-proBNP) has been validated as a cardiovascular biomarker, its ability to predict long-term outcomes after coronary artery bypass grafting (CABG) has not been fully explored. We aimed to assess the prognostic value of NT-proBNP beyond clinical risk prediction tools, and its relevance to follow-up events and interactions with different treatment selections. The study included 11,987 patients who underwent CABG who underwent surgery between 2014 and 2018. The primary end point was all-cause mortality during follow-up, whereas the secondary end points included cardiac death and major adverse cardiac and cerebrovascular events, which comprised death, myocardial infarction, and ischemic cerebrovascular accident. We evaluated the associations between NT-proBNP levels and outcome and the added prognostic value of NT-proBNP to clinical tools. Patients were followed up for a median of 4.0 years. Higher preoperative NT-proBNP levels were significantly associated with all-cause mortality, cardiac death, and major adverse cardiac and cerebrovascular events (all p <0.001). These associations remained significant after the full adjustment. Integration of NT-proBNP into clinical tools significantly improved the prediction accuracy for all end points. We also found that patients with higher preoperative NT-proBNP levels benefited more from β blockers (p for interaction = 0.045). In conclusion, we demonstrated the prognostic value of NT-proBNP in risk stratification and personalized treatment decisions in patients who underwent CABG.

The PreserFlo MicroShunt in the Context of Minimally Invasive Glaucoma Surgery: A Narrative Review

Recently, the quest for novel glaucoma surgical techniques and devices has been underway. Trabeculectomy remains the gold standard, but it requires the implantation of glaucoma drainage devices and frequent follow-ups, and it also carries a high risk of serious complications. The need for less invasive and safer procedures has led to the development of minimally invasive glaucoma surgery (MIGS), particularly for patients with mild-to-moderate disease. Among them, minimally invasive bleb surgery seems to be effective in classical glaucoma surgery, while maintaining MIGS benefits. The relatively new PreserFlo® MicroShunt (Santen, Osaka, Japan) is registered in Europe. It was released in 2019 for the treatment of patients with early-to-advanced open-angle glaucoma, where intraocular pressure (IOP) remains uncontrolled while on maximum tolerated medication and/or where glaucoma progression warrants surgery. This review focuses on the place of the PreserFlo MicroShunt, characterized by ab externo implantation, among MIGS procedures, discussing its advantages and disadvantages. The mechanisms of action, technical aspects, efficacy, and safety issues are summarized. The surgical technique, its efficacy, and safety profile are described, and directions for future studies are indicated. The PreserFlo MicroShunt ensures a high safety profile, minimal anatomical disruption, meaningful IOP-lowering effect, and ease of use for patients and physicians.

Coronary Revascularization in Patients With Diabetes: A Meta-Analysis of Randomized Controlled Trials and Propensity-Matched Studies

OBJECTIVE

Patients with diabetes have poorer outcomes with coronary artery disease (CAD) and pose a unique clinical population for revascularization. We performed a pairwise meta-analysis of randomized trials (RCTs) and propensity-matched observational studies (PMS) to compare the clinical outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with diabetes.

METHODS

A comprehensive literature search was performed to identify RCT and PMS studies comparing CABG with PCI in patients with diabetes with concurrent CAD. Studies were pooled using the random-effects model to perform a pairwise meta-analysis. Primary outcomes included long-term all-cause mortality, cardiac mortality, myocardial infarction (MI), major adverse cardiac and cerebrovascular events (MACCE), and repeat revascularization. Meta-regression was used to explore the effects of baseline risk factors on primary outcomes with moderate to high heterogeneity.

RESULTS

A total of 18 RCTs and 9 PMS with 28,846 patients were included. PCI was associated with increased long-term all-cause mortality (risk ratio [RR] = 1.34, P < 0.001), cardiac mortality (RR = 1.52, P < 0.001), MI (RR = 1.51, P = 0.009), MACCE (RR = 1.65, P < 0.001), and repeat revascularization (RR = 2.48, P < 0.001) compared with CABG. There was no difference in long-term stroke between the 2 groups (RR = 0.95, P = 0.82). At meta-regression, a greater proportion of female patients in studies was associated with a decreased protective benefit for CABG for long-term all-cause mortality but an increased protective benefit for long-term MI and repeat revascularization.

CONCLUSIONS

Revascularization of patients with diabetes using CABG is associated with significantly reduced long-term mortality, MI, MACCE, and repeat revascularizations. Future studies exploring the influence of gender on revascularization outcomes are necessary to elucidate the ideal treatment modality in patients with diabetes.

Single versus multiple arterial grafting in diabetic patients at 10 years: the Arterial Revascularization Trial

AIMS

To evaluate the impact of multiple arterial grafting (MAG) vs. single arterial grafting (SAG) in a post hoc analysis of 10-year outcomes in patients with diabetes mellitus (DM) from the Arterial Revascularization Trial (ART).

METHODS AND RESULTS

The primary endpoint was all-cause mortality and the secondary endpoint was a composite of major adverse cardiac events (MACE) at 10-year follow-up. Patients were stratified by diabetes status (non-DM and DM) and grafting strategy (MAG vs. SAG). A total of 3020 patients were included in the analysis; 716 (23.7%) had DM. Overall, 55.8% non-DM patients received MAG and 44.2% received SAG, while 56.6% DM patients received MAG and 43.4% received SAG. The use of MAG compared with SAG was associated with lower 10-year mortality for both non-DM [17.7 vs. 21.0%, adjusted hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.72-1.06] and DM patients (21.5 vs. 29.9%, adjusted HR 0.65, 95% CI 0.48-0.89; P for interaction = 0.12). For both groups, the rate of 10-year MACE was also lower for MAG vs. SAG. Overall, deep sternal wound infections (DSWIs) were uncommon but more frequent in the MAG vs. SAG group in both non-DM (3.3 vs. 2.1%) and DM patients (7.9 vs. 4.8%). The highest rates of DSWI were in insulin-treated patients receiving MAG (9.6 vs. 6.3%, when compared with SAG).

CONCLUSION

In this post hoc analysis of the ART, MAG was associated with substantially lower mortality rates at 10 years after coronary artery bypass grafting in patients with DM. Patients with DM receiving MAG had a higher incidence of DSWI, especially if insulin dependent.

Revascularization outcomes in diabetic patients presenting with acute coronary syndrome with non-ST elevation

Background

To compare the outcomes of diabetic patients hospitalized with non-ST elevation myocardial infarction (NSTEMI) or unstable angina (UA) referred for revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in a real-life setting.

Methods

The study included 1987 patients with diabetes mellitus enrolled from the biennial Acute Coronary Syndrome Israeli Survey between 2000 and 2016, who were hospitalized for NSTEMI or UA, and underwent either PCI (N = 1652, 83%) or CABG (N = 335, 17%). Propensity score-matching analysis compared all-cause mortality in 200 pairs (1:1) who underwent revascularization by either PCI or CABG.

Results

Independent predictors for CABG referral included 3-vessel coronary artery disease (OR 4.9, 95% CI 3.6–6.8, p < 0.001), absence of on-site cardiac surgery (OR 1.4, 95% CI 1.1–1.9, p = 0.013), no previous PCI (OR 1.5, 95% CI 1.1–2.2, p = 0.024) or MI (OR 1.7, 95% CI 1.2–2.6, p = 0.002). While at 2 years of follow-up, survival analysis revealed no differences in mortality risk between the surgical and percutaneous revascularization groups (log-rank p = 0.996), after 2 years CABG was associated with a significant survival benefit (HR 1.53, 95% CI 1.07–2.21; p = 0.021). Comparison of the propensity score matching pairs also revealed a consistent long-term advantage toward CABG (log-rank p = 0.031).

Conclusions

In a real-life setting, revascularization by CABG of diabetic patients hospitalized with NSTEMI/UA is associated with better long-term outcomes. Prospective randomized studies are warranted in order to provide more effective recommendations in future guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01595-5.

Outcomes after coronary artery bypass grafting and percutaneous coronary intervention in diabetic and non-diabetic patients

AIMS

To assess the prognosis of patients with coronary heart disease (CHD) after first myocardial revascularisation procedure in real-world practice and to compare the differences in outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) among diabetic and non-diabetic patients.

METHODS AND RESULTS

A database was compiled from the national hospital discharge register to collect data on all cardiac revascularisations performed in Finland in 2000-2015. The outcomes (all-cause deaths, cardiovascular (CV) deaths, major CV events and need for repeat revascularisation) after the first revascularisation were identified from the national registers at 28 day, 1 year, and 3 year time points.A total of 139 242 first-time revascularisations (89 493 PCI and 49 749 CABG) were performed during the study period. Of all the revascularised patients, 24% had diabetes, and 76% were non-diabetic patients. At day 28, the risk of fatal outcomes was lower after PCI than after CABG among non-diabetic patients, whereas no difference was seen among diabetic patients. In long-term follow-up the situation was reversed with PCI showing higher risk compared with CABG for most of the outcomes. In particular, at 3 year follow-up the risk of all-cause deaths was elevated among diabetic patients [HR 1.30 (95% CI 1.22-1.38) comparing PCI with CABG] more than among non-diabetic patients [HR 1.09 (1.04-1.15)]. The same was true for CV deaths [HR 1.29 (1.20-1.38) among diabetic patients, and HR 1.03 (0.98-1.08) among non-diabetic patients].

CONCLUSION

Although PCI was associated with better 28 day prognosis, CABG seemed to produce better long-term prognosis especially among diabetic patients.

Diabetes, heart failure, and myocardial revascularization: Is there a new message from the ISCHEMIA trial?

There is no evidence that the indications for myocardial revascularization differ between patients with and without diabetes. Accepted indications include stable angina that cannot be adequately managed by medication, acute coronary syndromes, severely reduced left ventricular (LV) function due to coronary artery disease, left main stenosis, and advanced coronary artery disease causing substantial inducible ischemia. The recent ISCHEMIA trial challenged the criterion of ischemia. With respect to its primary endpoint, ISCHEMIA showed no benefit of an invasive strategy with systematic myocardial revascularization in patients with stable angina and moderate-to-severe ischemia compared with a conservative strategy. However, myocardial revascularization resulted in a statistically significant and clinically meaningful reduction in angina and an improvement in quality of life. There was a significant reduction in prognostically relevant spontaneous myocardial infarction (MI) in the long term, which came at the cost of an increased rate of peri-interventional MI that was of minor prognostic relevance. The risk profile and number of patients included in the ISCHEMIA trial, as well as the duration of follow-up, are not sufficient to show that the lower incidence of spontaneous infarcts improved survival. In ISCHEMIA, there was no heterogeneity in treatment effect depending on diabetes.

Epidemiology of Coronary Artery Disease

Although the mortality of coronary artery disease (CAD) has declined over recent decades, CAD remains the leading cause of death in the United States (US) and presents a significant economic burden. Epidemiologic studies have identified numerous risk factors for CAD. Some risk factors-including smoking, hypertension, dyslipidemia, and physical inactivity-are decreasing within the US population while Others, including advanced age, diabetes, and obesity are increasing. The most significant historic advances in CAD therapy were the development of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and lipid-lowering medications. Contemporary management of CAD includes primary and secondary prevention via medical management and revascularization when appropriate based on best available evidence. Despite the increasing prevalence of CAD nationwide, there has been a steady decline in the number of CABGs and PCIs performed in the US for the past decade. Patients with CABG are becoming older and with more comorbid conditions, although mortality associated with CABG has remained steady.

Investigation Into the Risk Factors Related to In-stent Restenosis in Elderly Patients With Coronary Heart Disease and Type 2 Diabetes Within 2 Years After the First Drug-Eluting Stent Implantation

Background

The present study aims to explore risk factors related to in-stent restenosis (ISR) in elderly patients with coronary heart disease and type 2 diabetes within 2 years after the first drug-eluting stent (DES) implantation.

Methods

This case-control study retrospectively analyzed the clinical data of patients with coronary heart disease and diabetes undergoing percutaneous coronary intervention (PCI) in Shenzhen Sun Yat-sen Cardiovascular Hospital between January 2010 and March 2020. Univariate and multivariate models were used to assess independent factors for DES-ISR. Categorical principal component analysis of clinical variables was performed to determine important components for DES-ISR. Nomogram was constructed to quantitatively predict the probability of DES-ISR development. The diagnostic potential of clinical variables was determined by receiver operating characteristic curve.

Results

In the derivation cohort, 1,741 cases were included in this study, and a total of 227 pairs of cases and controls were generated by propensity score matching. In the validation cohort, 102 cases were included with 19 cases (18.6%) with DES-ISR. Glomerular filtration rate &lt;60 ml/min/1.73 m2, fasting blood glucose ≥6.5 mmol/L, multivessel coronary artery disease, coronary artery diffuse disease, PCI operation time (≥60 min), emergency PCI were associated with ISR. High Nomogram score was associated with the increased risk of ISR. Further analysis of the validation cohort showed that higher levels of HbA1c-coefficient of variation (CV) were significantly associated with the increased risk of ISR. HbA1c-CV exhibited good predictive ability for ISR in the validation cohort.

Conclusions

In conclusion, the fasting blood glucose level during the perioperative period of emergency PCI and the long-term variation of HbA1c during the follow-up period are related to the incidence of DES-ISR and the degree of stenosis. Reducing blood glucose fluctuations may decrease the risk of DES-ISR.

Percutaneous coronary intervention in insulin-treated diabetic patients: A meta-analysis

Background

This meta‐analysis of randomized controlled trials (RCTs) compared long‐term adverse clinical outcomes of percutaneous coronary intervention (PCI) in insulin‐treated diabetes mellitus (ITDM) and non‐ITDM patients.

Methods

This is a meta‐analysis study. The PubMed and Embase databases were searched for articles on long‐term adverse clinical outcomes of PCI in ITDM and non‐ITDM patients. The risk ratios (RR) and 95% confidence intervals (CI) were calculated.

Results

A total of 11 related RCTs involving 8853 DM patients were included. Compared with non‐ITDM patients, ITDM patients had significantly higher all‐cause mortality (ACM) (RR = 1.52, 95% CI: 1.25–1.85, p_{heterogeneity} = .689, I² = 0%), major adverse cardiac and cerebrovascular events (MACCE) (RR = 1.35, 95% CI: 1.18–1.55, p_{heterogeneity} = .57, I² = 0%), myocardial infarction (MI) (RR = 1.41, 95% CI: 1.16–1.72, p_{heterogeneity} = .962, I² = 0%), and stent thrombosis (ST) (RR = 1.75, 95% CI: 1.23–2.48, p_{heterogeneity} = .159, I² = 32.4%). No significant difference was found in the target lesion revascularization (TLR) and target vessel revascularization (TVR) between the ITDM and non‐ITDM groups.

Conclusions

The results showed that ITDM patients had significantly higher ACM, MACCE, MI, and ST, compared with non‐ITDM patients.

Acute coronary syndromes in diabetic patients, outcome, revascularization, and antithrombotic therapy

Diabetes exacerbates the progression of atherosclerosis and is associated with increased risk of developing acute coronary syndrome (ACS). Approximatively 25-30% of patients admitted for ACS have diabetes. ACS occurs earlier in diabetics and is associated with increased mortality and a higher risk of recurrent ischemic events. An increased proinflammatory and prothrombotic state is involved in the poorer outcomes of diabetic patients. In the past decade advancement in both percutaneous coronary intervention (PCI) and coronary artery by-pass graft (CABG) techniques and more potent antiplatelet drugs like prasugrel and ticagrelor improved outcomes of diabetic patients with ACS, but this population still experiences worse outcomes compared to non-diabetic patients. While in ST elevation myocardial infarction urgent PCI is the method of choice for revascularization, in patients with non-ST elevation ACS an early invasive approach is suggested by the guidelines, but in the setting of multivessel (MV) or complex coronary artery disease (CAD) the revascularization strategy is less clear. This review describes the accumulating evidence regarding factors involved in promoting increased incidence and poor prognosis of ACS in patients with diabetes, the evolution over time of prognosis and outcomes, revascularization strategies and antithrombotic therapy studied until now.

Revascularization strategies in patients with diabetes and stable ischemic heart disease: a systematic review and meta-analysis of randomized trials

AIMS

The optimal treatment strategy comparing invasive revascularization versus optimal medical therapy (OMT) in patients with diabetes mellitus (DM) and stable ischemic heart disease (SIHD) still remains unclear. We aimed to investigate clinical outcomes of invasive revascularization (percutaneous coronary intervention, coronary artery bypass grafting or both) versus OMT in patients with DM and SIHD from updated published randomised-controlled trials (RCTs).

METHODS

We conducted a comprehensive literature search through PubMed and EMBASE to investigate the effect of revascularization versus OMT for patients with DM and SIHD. The studies were limited to RCTs or their subgroup data for a meta-analysis. The outcomes of interest were major adverse cardiovascular events (MACE) in patients with DM and SIHD.

RESULTS

Our search identified subgroup data with DM of four RCTs including a total of 5742 patients with SIHD. Our results showed that invasive revascularization was not associated with a decreased risk of MACE when compared to OMT [hazard ratio (95% confidence interval): 0.95 (0.85-1.05), P = 0.31; I2 = 0%].

CONCLUSION

Invasive revascularization was not associated with a decreased risk of MACE when compared with OMT.

The Impact of the Stress Hyperglycemia Ratio on Short-term and Long-term Poor Prognosis in Patients With Acute Coronary Syndrome: Insight From a Large Cohort Study in Asia

OBJECTIVE

In recent years, some studies have indicated that a novel marker described as the stress hyperglycemia ratio (SHR) can reflect true acute hyperglycemic status and is associated with the short-term poor prognosis in patients with acute myocardial infarction. In the current study we evaluated the association of SHR with adverse cardiovascular events among patients with acute coronary syndrome (ACS).

RESEARCH DESIGN AND METHODS

We consecutively enrolled 5,562 ACS patients who underwent drug-eluting stent (DES) implantation. All subjects were divided into five groups according to SHR, which was determined by the following formula: ABG / [(28.7 × HbA1c %) - 46.7], where ABG is admission blood glucose level. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCE) at the 2-year follow-up, and the secondary end point included major adverse cardiovascular events (MACE) at 2-year follow-up, cardiac death, and nonfatal myocardial infarction (MI) at 2-year follow-up and in-hospital cardiac death and nonfatal MI.

RESULTS

A total of 643 MACCE were recorded during a median follow-up of 28.3 months. Kaplan-Meier survival analysis showed the lowest MACCE incidence in quintile 3 (P < 0.001). Moreover, the outcomes of restricted cubic spline analysis suggested that there was a U-shaped or J-shaped association between the SHR and early and late cardiovascular outcomes even after adjustment for other confounding factors.

CONCLUSIONS

There were U-shaped associations of SHR with MACCE rate and MACE rate at 2-year follow-ups and J-shaped associations of SHR with in-hospital cardiac death and MI and that at 2-year follow-up in ACS patients who underwent DES implantation, and the inflection point of SHR for poor prognosis was 0.78.

Discrepancy between plaque vulnerability and functional severity of angiographically intermediate coronary artery lesions

This study sought to investigate the relationship between physiological severity and plaque vulnerability of intermediate coronary artery stenoses as assessed by fractional flow reserve (FFR) and near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS). We included vessels where both FFR and NIRS-IVUS were performed. A positive FFR was defined as FFR ≤ 0.80. Lipid core burden index of the entire target vessel (TV-LCBI), maximum LCBI in 4 mm (maxLCBI_4mm), and maximum plaque burden (PB) were evaluated using NIRS-IVUS. A vulnerable plaque was defined as a lipid-rich plaque (maxLCBI4_mm ≥ 400) with large PB (≥ 70%). A total of 59 vessels of 45 patients were included. Median FFR value was 0.75 [interquartile 0.72, 0.82]. An FFR value of ≤ 0.80 was observed in 42 vessels (71%). TV-LCBI (correlation coefficient [CC] = - 0.331, p = 0.011), lesion length (CC = - 0.350, p = 0.007), and PB (CC = - 0.230, p = 0.080) negatively correlated with FFR value, while maxLCBI_4mm did not (CC = - 0.156, p = 0.24). The prevalence of vulnerable plaques (26.2% vs. 29.4%, p > 0.99) and mean TV-LCBI, maxLCBI_4mm, and PB values were not significantly different between the vessels with FFR ≤ 0.80 and those with FFR > 0.80. In multivariable logistic models, diabetes mellitus (p = 0.003) and hemoglobin A1c (p = 0.012) were associated with the presence of a vulnerable plaque. In conclusion, the results of the present study suggested that FFR may reflect total lipid burden but not necessarily plaque vulnerability. In patients with coronary artery disease and a high likelihood of rapid atherosclerosis progression, such as diabetes mellitus patients, assessing plaque vulnerability in addition to the functional severity of coronary artery lesions may help stratify better the risk of future events.

A comparison of drug-eluting stent and coronary artery bypass grafting in mildly to moderately ischemic heart failure

Aims

The best revascularization strategy for patients with ischaemic heart failure (IHF) remains unclear. Current evidence and guidelines mainly focus on patients with severe ischaemic heart failure (ejection fraction [EF] < 35%). There are limited data comparing clinical outcomes of coronary artery bypass grafting (CABG) with implantation of drug‐eluting stents (DESs) in patients with mild to moderate ischaemic heart failure (EF 35–50%). It is therefore unknown whether percutaneous coronary intervention (PCI) with DES implantation can provide comparable outcomes to CABG in these patients.

Methods and results

From January 2016 to December 2017, we enrolled patients with mildly to moderately reduced EF (35–50%) who had undergone PCI with DESs or CABG. Patients with a history of CABG, presented with acute ST‐elevation myocardial infarction (MI) or acute heart failure, and patients who had undergone CABG concomitant valvular or aortic surgery were excluded. Propensity score‐matching analysis was performed between the two groups. Kaplan–Meier analysis and multivariate Cox proportional hazard regression were applied to assess all‐cause mortality and individual end points. A total of 2050 patients (1330 PCIs and 720 CABGs) were included, and median follow‐up was 45 months (interquartile range 40 to 54). There were significant differences in all‐cause death between the two groups: 77 patients in the PCI group and 27 in the CABG group (DES vs. CABG: 5.8% vs. 3.8%, P = 0.045). After propensity score matching for the entire population, 601 matched pairs were obtained. The long‐term cumulative rate of all‐cause death was significantly different between the two groups (DES vs. CABG: 5.8% vs. 2.7%, P = 0.006). No differences were found in the rates of cardiac death (DES vs. CABG: 4.8% vs. 3.0%, P = 0.096), recurrent MI (DES vs. CABG: 4.0% vs. 2.8%, P = 0.234), and stroke (DES vs. CABG: 6.8% vs. 5.2%, P = 0.163). The rate of repeat coronary revascularization was significantly higher in the PCI group than in the CABG group (12.1% vs. 6.0%, P = 0.000).

Conclusions

Considering the higher long‐term survival rate and lower repeat‐revascularization rate, CABG may be superior to DES implantation in patients with mildly to moderately reduced EF (35–50%) and significant CAD.

Revascularization Strategies in Patients with Diabetes and Acute Coronary Syndromes

PURPOSE OF REVIEW

To review the current evidence for coronary revascularization in patients with diabetes mellitus (DM) in the setting of an acute coronary syndrome (ACS).

RECENT FINDINGS

In patients with DM and stable multivessel ischemic heart disease, coronary artery bypass graft surgery (CABG) has been observed to be superior to percutaneous coronary intervention (PCI) in long-term follow-up, leading to lower rates of all-cause mortality, myocardial infarction, and repeat revascularization. In the ACS setting, PCI remains the most frequently performed procedure. In patients with an ST-segment-elevation myocardial infarction (STEMI), primary PCI should be the revascularization method of choice, whenever feasible. Controversy still exists regarding when and how to deal with possible residual lesions. In the non-ST-segment-elevation (NSTE) ACS setting, although there are no data from randomized controlled trials (RCTs), recent observational data and sub-analyses of randomized studies have suggested that CABG may be the preferred approach for patients with DM and multivessel coronary disease. There is a paucity of RCTs evaluating revascularization strategies (PCI and CABG) in patients with DM and ACS. CABG may be a viable strategy, leading to improved outcomes, especially following NSTE-ACS.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Short- and long-term cardiovascular outcomes in insulin-treated versus non-insulin-treated diabetes mellitus patients after percutaneous coronary intervention: A systematic review and meta-analysis

Aims

This study aims to assess differences in severity of short-term (<1 year) and long-term (≥1 year) adverse CV outcomes after PCI in insulin-treated vs. non-insulin-treated diabetes mellitus (DM) patients.

Methods

A systematic search on Pubmed and Embase led to the incorporation of 29 studies that compared post-percutaneous coronary interventional outcomes in insulin-treated and non-insulin-treated diabetes mellitus. Diabetes mellitus (type 2) was defined as fasting blood glucose (FBG) level of >7.0 mmol/L or with an oral glucose tolerance test (OGTT) level of >11.1 mmol/L at least on two separate occasions. Adverse CV outcomes were assessed in insulin-treated and non-insulin-treated DM after the PCI procedure considered for the analyses were mortality, MACE, TLR, TVR, MI, stent thrombosis, target lesion failure (TLF), and need for-post PCI CABG. Data were pooled and analyzed using Review Manager 5.3, and risk ratios (RR) with respective 95% confidence intervals (CI) were calculated.The statistical analyses were carried out by Review Manager v.5.3, and the data were pooled using a random-effects model. Risk ratios (RRs) with 95% confidence intervals (CI) were reported along with forest plots. The chi-square test was performed to assess for differences between the subgroups. Heterogeneity across studies was evaluated using Higgins I² statistics. Visual inspection of the funnel plot and Begg's regression test were used to assess publication bias.

Results

A total of 40,527 patients (11742 in the Insulin-treated diabetes mellitus group and 28785 in the non-insulin-treated DM group) who underwent PCI were included. The pooled analysis of short-term follow up outcomes preceding PCI demonstrated a significantly higher risk of mortality (RR = 1.75 [1.24,2.47]; p = 0.002), MI (RR = 1.81[1.14,2.87]; p = 0.01], stent thrombosis (RR = 1.63[1.13, 2.35]; p = 0.009) and target lesion revascularization (TLR) (RR = 1.29[1.02,1.63]; p = 0.03) in insulin-treated DM patients. Similarly, analysis of long-term follow-up studies depicted a significantly higher risk mortality (RR = 1.55 [1.22, 1.97]; p = 0.0003), MI (RR = 1.63 [1.35, 1.97]; p=<0.00001), MACE (R = 1.47 [1.31, 1.65]; p=<0.00001), stent thrombosis (RR = 1.54 [1.19,1.99]; p = 0.001), TLR (RR = 1.40 [1.18, 1.66]; p = 0.0001), target vessel revascularization (TVR) (RR = 1.35 [1.11, 1.64]; p = 0.003) in insulin-treated DM group after PCI versus non-insulin-treated DM patients.

Conclusion

Despite a tremendous technical success rate of multi-vessel stenting, people living with diabetes who were being treated with insulin had higher long-term, and short-term mortality rates, MI, TLR, TVR, and stroke compared to people living with diabetes who were being treated with means other than insulin and are more prone to detrimental cardiovascular outcomes.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.

Reassessing Revascularization Strategies in Coronary Artery Disease and Type 2 Diabetes Mellitus

Percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is still controversial in patients with coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM). Here, we aimed to evaluate the long-term follow-up events of PCI and CABG in these populations. Relevant randomized controlled trials were retrieved from PubMed, Embase, and the Cochrane databases. The pooled results were represented as risk ratios (RRs) with 95% confidence intervals (CIs) with STATA software. A total of six trials with 1,766 patients who received CABG and 2,262 patients who received PCI were included in our study. Patients in the CABG group were significantly associated with a lower all-cause mortality compared with those in the PCI group (RR = 0.74, 95% CI = 0.56–0.98, P = 0.037). Cardiac mortality, recurrent myocardial infarction, and repeat revascularization were also significantly lower in the CABG group (RR = 0.79, 95% CI = 0.40–1.53, P = 0.479; RR = 0.70, 95% CI = 0.32–1.56, P = 0.387; and RR = 0.36, 95% CI = 0.28–0.46, P < 0.0001; respectively). However, compared with the PCI group, the cerebral vascular accident was higher in the CABG group (RR = 2.18, 95% CI = 1.43–3.33, P < 0.0001). There was no publication bias in our study. CABG revascularization was associated with significantly lower long-term adverse clinical outcomes, except cerebral vascular accident, compared with PCI in patients with CAD and T2DM.

Systematic Review Registration: PROSPERO, identifier: CRD42020216014.

Ten-year all-cause death after percutaneous or surgical revascularization in diabetic patients with complex coronary artery disease

Aims

The aim of this article was to compare rates of all-cause death at 10 years following coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in patients with or without diabetes.

Methods and results

The SYNTAXES study evaluated up to 10-year survival of 1800 patients with three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD) randomized to receive either PCI or CABG in the SYNTAX trial. Ten-year all-cause death according to diabetic status and revascularization strategy was examined. In diabetics (n = 452), the risk of mortality was numerically higher with PCI compared with CABG at 5 years [19.6% vs. 13.3%, hazard ratio (HR): 1.53, 95% confidence interval (CI): 0.96, 2.43, P = 0.075], with the opposite seen between 5 and 10 years (PCI vs. CABG: 20.8% vs. 24.4%, HR: 0.82, 95% CI: 0.52, 1.27, P = 0.366). Irrespective of diabetic status, there was no significant difference in all-cause death at 10 years between patients receiving PCI or CABG, the absolute treatment difference was 1.9% in diabetics (PCI vs. CABG: 36.4% vs. 34.5%, difference: 1.9%, 95% CI: −7.6%, 11.1%, P = 0.551). Among insulin-treated patients (n = 182), all-cause death at 10 years was numerically higher with PCI (47.9% vs. 39.6%, difference: 8.2%, 95% CI: −6.5%, 22.5%, P = 0.227).

Conclusions

The treatment effects of PCI vs. CABG on all-cause death at 10 years in patients with 3VD and/or LMCAD were similar irrespective of the presence of diabetes. There may, however, be a survival benefit with CABG in patients with insulin-treated diabetes. The association between revascularization strategy and very long-term ischaemic and safety outcomes for patients with diabetes needs further investigation in dedicated trials.

Trial registration

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

Ten-year Outcomes After Drug-Eluting Stents or Bypass Surgery for Left Main Coronary Disease in Patients With and Without Diabetes Mellitus: The PRECOMBAT Extended Follow-Up Study

Background

Several trials reported differential outcomes after percutaneous coronary intervention with drug‐eluting stents (DES) and coronary‐artery bypass grafting (CABG) for multivessel coronary disease according to the presence of diabetes mellitus (DM). However, it is not well recognized how DM status affects very‐long‐term (10‐year) outcomes after DES and CABG for left main coronary artery disease.

Methods and Results

In the PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty using Sirolimus‐Eluting Stent in Patients with Left Main Coronary Artery Disease) trial, patients with LMCA were randomly assigned to undergo PCI with sirolimus‐eluting stents (n=300) or CABG (n=300). The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (MACCE; a composite of death from any cause, myocardial infarction, stroke, or ischemia‐driven target‐vessel revascularization). Outcomes were examined in patients with (n=192) and without (n=408) medically treated diabetes. The follow‐up was extended to at least 10 years for all patients (median, 11.3 years). The 10‐year rates of MACCE were not significantly different between DES and CABG in patients with DM (36.3% versus 26.7%, respectively; hazard ratio [HR], 1.35; 95% CI, 0.83–2.19; P=0.23) and without DM (25.3% versus 22.9%, respectively; HR, 1.15; 95% CI, 0.79–1.67; P=0.48) (P‐for‐interaction=0.48). There were no significant between‐group differences in composite of death, MI, or stroke, and all‐cause mortality, regardless of DM status. TVR rates were consistently higher after DES than CABG.

Conclusions

In this 10‐year extended follow‐up of PRECOMBAT, we found no significant difference between DES and CABG with respect to the incidences of MACCE, serious composite outcome, and all‐cause mortality in patients with and without DM with LMCA disease. However, owing to the limited number of patients and no adjustment for multiple testing, overall findings should be considered hypothesis‐generating, highlighting the need for further research.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03871127 and NCT00422968.

Myocardial Revascularization Surgery: JACC Historical Breakthroughs in Perspective

Coronary artery bypass grafting (CABG) was introduced in the 1960s as the first procedure for direct coronary artery revascularization and rapidly became one of the most common surgical procedures worldwide, with an overall total of more than 20 million operations performed. CABG continues to be the most common cardiac surgical procedure performed and has been one of the most carefully studied therapies. Best CABG techniques, optimal bypass conduits, and appropriate patient selection have been rigorously tested in landmark clinical trials, some of which have resolved controversy and most of which have stoked further debate and trials. The evolution of CABG cannot be properly portrayed without presenting it in the context of the parallel development of percutaneous coronary intervention. In this Historical Perspective, we a provide a broad overview of the history of coronary revascularization with a focus on the foundations, evolution, best evidence, and future directions of CABG.

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with coronary heart disease and type 2 diabetes mellitus: Cumulative meta-analysis

Previous meta‐analyses showed that coronary artery bypass grafting (CABG) has lower all‐cause mortality than percutaneous coronary intervention (PCI) for the management of coronary heart disease (CHD), but the long‐term outcomes were not analyzed thoroughly in patients with type 2 diabetes mellitus (T2DM). To perform a meta‐analysis of randomized controlled trials (RCTs) to explore the long‐term effectiveness between CABG and PCI in patients with T2DM and study the temporal trends using a cumulative meta‐analysis. PubMed, Embase, Cochrane library, and Clinical Trials Registry for eligible RCTs published up to September 2020. The outcomes were all‐cause death, cardiac death, myocardial infarction, repeat revascularization, and stroke. Nine RCTs and 4566 patients were included. CABG resulted in better outcomes than PCI in terms of all‐cause death (RR = 1.41, 95%CI: 1.22–1.63, p < 0.001), cardiac death (RR = 1.56, 95%CI: 1.25–1.95, p < 0.001), and repeat revascularization (RR = 2.68, 95%CI: 1.86–3.85, p < 0.001), but with difference regarding the occurrence of myocardial infarction (RR = 1.20, 95%CI: 0.78–1.85, p = 0.414), while PCI was associated with better outcomes in terms of stroke occurrence (RR = 0.51, 95%CI: 0.34–0.77, p = 0.001). The cumulative meta‐analysis for all‐cause death showed that the differences between CABG and PCI started to be significant at 3 years of follow‐up, while the difference became significant at 5 years for cardiac death. In patients with CHD and T2DM, CABG results in better outcomes than PCI in terms of all‐cause death, cardiac mortality, and repeat revascularization, while PCI had better outcomes in terms of stroke. The differences are mainly observed over the long‐term follow‐up.

Advances in revascularization of the left coronary artery

Ischaemic heart disease is the most common cardiovascular disease worldwide, and it contributes to a significant source of morbidity and mortality internationally. It can be asymptomatic for many years and present suddenly with acute coronary syndrome or can be progressive with angina and eventual acute myocardial infarction. Diseases of the left coronary system can be drastic and fatal if not managed correctly. With ongoing increase in the practice of percutaneous intervention; patient demographics for conventional coronary artery bypass grafting surgery have more risk factors than before. Conventional bypass surgery has also evolved to include minimally invasive and hybrid techniques. Although some evidence supports each approach, controversies remain.

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.

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.

Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Diabetes and Multivessel Coronary Disease

BACKGROUND

There remains a paucity of real-world observational evidence comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with diabetes and multivessel coronary artery disease (CAD).

OBJECTIVES

This study compared early and long-term outcomes of PCI versus CABG in patients with diabetes.

METHODS

Clinical and administrative databases in Ontario, Canada were linked to obtain records of all patients with diabetes with angiographic evidence of 2- or 3-vessel CAD who were treated with either PCI or isolated CABG from 2008 to 2017. A 1:1 propensity score match was performed to account for baseline differences. All-cause mortality and the composite of myocardial infarction, repeat revascularization, stroke, or death (termed major cardiovascular and cerebrovascular events [MACCEs]) were compared between the matched groups using a stratified log-rank test and Cox proportional hazards model.

RESULTS

A total of 4,519 and 9,716 patients underwent PCI and CABG, respectively. Before matching, patients who underwent CABG were significantly younger (age 65.7 years vs. 68.3 years), were more likely to be men (78% vs. 73%) and had more severe CAD. Propensity score matching based on 23 baseline covariates yielded 4,301 well-balanced pairs. There was no difference in early mortality between PCI and CABG (2.4% vs. 2.3%; p = 0.721) after matching. The median and maximum follow-ups were 5.5 and 11.5 years, respectively. All-cause mortality (hazard ratio [HR]: 1.39; 95% CI: 1.28 to 1.51) and overall MACCEs (HR: 1.99; 95% CI: 1.86 to 2.12) were significantly higher with PCI compared with CABG.

CONCLUSIONS

In patients with multivessel CAD and diabetes, CABG was associated with improved long-term mortality and freedom from MACCEs compared with PCI.

Comparison of coronary artery bypass graft versus drug-eluting stents in dialysis patients: an updated systemic review and meta-analysis

INTRODUCTION

As percutaneous coronary intervention (PCI) technologies have been far improved, we hence conducted an updated systemic review and meta-analysis to determine the comparability between coronary artery bypass graft (CABG) and PCI with drug-eluting stent (DES) in ESRD patients.

METHODS

We comprehensively searched the databases of MEDLINE, EMBASE, PUBMED and the Cochrane from inception to January 2020. Included studies were published observational studies that compared the risk of cardiovascular outcomes among dialysis patients with CABG and DES. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. Subgroup analyses and meta-regression were performed to explore heterogeneity.

RESULTS

Thirteen studies were included in this analysis, involving total 56 422 (CABG 21 740 and PCI 34 682). Compared with DES, our study demonstrated CABG had higher 30-day mortality [odds ratio (OR) 3.85, P = 0.009] but lower cardiac mortality (OR 0.78, P < 0.001), myocardial infarction (OR 0.5, P < 0.001) and repeat revascularization (OR 0.35, P < 0.001). No statistical differences were found between CABG and DES for long-term mortality (OR 0.92, P = 0.055), composite outcomes (OR 0.88, P = 0.112) and stroke (OR 1.49, P = 0.457). Meta-regression suggested diabetes and the presence of left main coronary artery disease as an effect modifier of long-term mortality.

CONCLUSION

PCI with DES shared similar long-term mortality, composite outcomes and stroke outcomes to CABG among dialysis patients but still was associated with an improved 30-day survival. However, CABG had better rates of myocardial infarction, repeat revascularization and cardiac mortality.