What outcomes have been reported for percutaneous coronary intervention (PCI) to treat CAD in patients with comorbid diabetes?

Updated: Nov 27, 2019
  • Author: George A Stouffer, III, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

Patients with diabetes mellitus appear to constitute an exception to the general findings that balloon angioplasty and bypass surgery yield essentially equivalent results in patients with multivessel disease.

Among diabetic patients in the BARI trial, 5-year survival was 65.5% in those treated by balloon angioplasty and 80.6% for those treated with bypass surgery. [22] The improved survival with surgery was due to reduced cardiac mortality (5.8% vs 20.6%) and was confined to those receiving at least one internal thoracic artery graft. Better survival among diabetic patients with multivessel disease treated with bypass surgery rather than angioplasty was also observed in a large retrospective study.

The BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial randomized 2364 men and women with type 2 diabetes mellitus, documented CAD, stable symptoms, and myocardial ischemia treated with optimal medical therapy to an initial strategy of either coronary revascularization or watchful waiting with the option of subsequent revascularization. [35] At 5 years, rates of survival or the composite endpoint of cardiovascular death, MI, and stroke did not differ significantly between the groups.

A substudy of the BARI 2D trial reported that the coronary revascularization strategy improved outcomes at the 3-year follow-up, with patients experiencing a lower rate of worsening angina, new angina, and subsequent coronary revascularizations, as well as a higher rate of angina-free status. [36]

The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus Optimal Management of Multivessel Disease) trial randomly assigned 1900 patients with diabetes and multivessel CAD to either PCI with a DES or CABG. At 5 years, the rate of primary outcome—a composite of death, nonfatal MI, or nonfatal stroke—was lower in the CABG group (18.7%) than in the DES group (26.6%). CABG also had lower rates of death (10.9% vs 16.3% for PCI) and MI (6.0% vs 13.9% for PCI) but higher rates of stroke (5.2% vs 2.4% for PCI). [37]

A meta-analysis of 3131 patients from eight randomized, controlled trials (including SYNTAX and FREEDOM) that compared CABG with PCI in patients with diabetes suggested that all-cause mortality was lower with CABG than with PCI. [38]

In summary, in deciding between PCI and CABG in patients with diabetes mellitus and complex multivessel CAD, a Heart Team approach is recommended. CABG is generally recommended in preference to PCI, provided that the patient is a good candidate for surgery, there is extensive CAD (eg, three-vessel CAD or complex two-vessel CAD involving the proximal LAD artery), and the LAD artery can be anastomosed with a left internal mammary artery (LIMA) graft, CABG is generally recommended in preference to PCI.


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