Strategies for multivessel revascularization in patients with diabetes.

Abstract

BACKGROUND:

In some randomized trials comparing revascularization strategies for patients with diabetes, coronary-artery bypass grafting (CABG) has had a better outcome than percutaneous coronary intervention (PCI). We sought to discover whether aggressive medical therapy and the use of drug-eluting stents could alter the revascularization approach for patients with diabetes and multivessel coronary artery disease.

METHODS:

In this randomized trial, we assigned patients with diabetes and multivessel coronary artery disease to undergo either PCI with drug-eluting stents or CABG. The patients were followed for a minimum of 2 years (median among survivors, 3.8 years). All patients were prescribed currently recommended medical therapies for the control of low-density lipoprotein cholesterol, systolic blood pressure, and glycated hemoglobin. The primary outcome measure was a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke.

RESULTS:

From 2005 through 2010, we enrolled 1900 patients at 140 international centers. The patients' mean age was 63.1±9.1 years, 29% were women, and 83% had three-vessel disease. The primary outcome occurred more frequently in the PCI group (P=0.005), with 5-year rates of 26.6% in the PCI group and 18.7% in the CABG group. The benefit of CABG was driven by differences in rates of both myocardial infarction (P<0.001) and death from any cause (P=0.049). Stroke was more frequent in the CABG group, with 5-year rates of 2.4% in the PCI group and 5.2% in the CABG group (P=0.03).

CONCLUSIONS:

For patients with diabetes and advanced coronary artery disease, CABG was superior to PCI in that it significantly reduced rates of death and myocardial infarction, with a higher rate of stroke. (Funded by the National Heart, Lung, and Blood Institute and others; FREEDOM ClinicalTrials.gov number, NCT00086450.).

• Authors: Michael E Farkouh, Michael Domanski, Lynn A Sleeper, Flora S Siami, George Dangas, Michael Mack, May Yang, David J Cohen, Yves Rosenberg, Scott D Solomon, Akshay S Desai, Bernard J Gersh, Elizabeth A Magnuson, Alexandra Lansky, Robin Boineau, Jesse Weinberger, Krishnan Ramanathan, J Eduardo Sousa, Jamie Rankin, Balram Bhargava, John Buse, Whady Hueb, Craig R Smith, Victoria Muratov, Sameer Bansilal, Spencer King 3rd, Michel Bertrand, Valentin Fuster, FREEDOM Trial Investigators
• Journal: The New England journal of medicine (N Engl J Med) Vol. 367 Issue 25 Pg. 2375-84 (Dec 20 2012) ISSN: 1533-4406 [Electronic] United States
• PMID: 23121323 (Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Gov't)

Topics

• Aged
• Angioplasty, Balloon, Coronary
• Cardiovascular Diseases (mortality)
• Coronary Artery Bypass
• Coronary Artery Disease (complications, surgery, therapy)
• Diabetes Complications (surgery, therapy)
• Drug-Eluting Stents
• Female
• Humans
• Kaplan-Meier Estimate
• Male
• Middle Aged
• Myocardial Infarction (epidemiology)
• Stroke (epidemiology)