Comparable outcomes between PCI and surgery in diabetic patients with acute coronary syndromes and multivessel disease


Yanai Ben-Gal (Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel) and others report in Circulation: Coronary Interventions that the one-year rates of myocardial infarction and death in diabetic patients with acute coronary syndromes and multivessel disease who have undergone percutaneous coronary intervention (PCI) are comparable to those of patients in this subgroup who have undergone coronary artery bypass grafting (CABG). However, the authors note that PCI is associated with a greater need for repeat revascularisation.

Ben-Gal et al state that the FREEDOM (Future revascularisation evaluation in patients with diabetes mellitus: optimal management of multivessel disease) trial indicated that CABG was associated with “greater freedom from the composite endpoint of death, stroke, or myocardial infarcton” compared with PCI in patients with diabetes. However, they note that patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) undergoing emergent or urgent angiography were excluded from the study and that, therefore, the “optimal revascularisation strategy for patients with diabetes, multivessel disease, and NSTEACS after early angiography is not certain”. They add that the aim of the present study, by reviewing data from the ACUITY (Acute catheterisation and early intervention triage strategy) trial, was to “compare outcomes of PCI vs. CABG in patients with diabetes mellitus and multivessel disease, specifically in high-risk patients with involvement of the left anterior descending coronary artery”.

Of the 13,819 patients in the overall study population, 1,772 had both diabetes and multivessel disease. In this subgroup, 1,349 underwent PCI—of whom, 89.5% received a stent with 60.7% of these patients receiving a drug-eluting stent—and 423 underwent CABG.

According to multivariate analysis, the one-month rate of death was significantly lower in PCI patients than in CABG patients: 1.6% vs. 4.7% (p=0.0003). The rates of myocardial infarction (7.1% vs. 11.7%, respectively; p=0.01) and major bleeding (9.8% vs. 54.1%; p=0.0001) were also lower in the PCI group at this time point. However, PCI was associated with significantly more ischaemia-driven revascularisation (4.7% vs. 1.2% for CABG; p=0.001).

Ben-Gal et al report that at one year, there were no significant differences between groups in the rates of death or myocardial infarction. However, as with the one-month outcomes, PCI was associated with a significantly increased need for ischaemia-driven revascularisation: 16.6% vs. 4% for CABG (p<0.0001). The authors add that in a propensity-matched analysis, there were  no differences in the rates of mortality or myocardial infarction between PCI and CABG at one month or one year, PCI was again associated with more ischaemia-driven revascularisation (both at one month and one year) and less major bleeding and acute renal failure (one month).

Ben-Gal et al conclude that—“as with all revascularisation decisions”—in patients with patients with diabetes and multivessel disease, “a one size fits all approach is inferior to a more sophisticated heart-team-based decision-making process, which considers individual clinical and anatomical risk, as well as preferences and life goals.” They also note that PCI might be preferred in diabetic patients at high risk of bleeding or acute kidney complications or those in whom “rapid reperfusion is essential” (ie. when there is ongoing ischaemia) whereas CABG “should preferred as anatomic disease complexity increases”.

Viveca Ritsinger (Cardiology Unit, Department of Medicine, Karolinska University Hospital, Solna, Sweden) and others also reviewed the use of PCI in patients with diabetes. Like Ben-Gal et al’s study, their study was published Circulation: Coronary Interventions. The aim of the study, authors report, was to “explore complications and causes of mortality after a first PCI in unselected patients with and without diabetes mellitus in a modern setting.”

Reviewing data from SCAAR (Swedish Coronary Angiography Angioplasty Registry), Ritsinger et al found patients with diabetes had a worse prognosis after PCI than patients without diabetes and this was particularly true of diabetic patients who were insulin dependent. They state: “Patients on insulin therapy run a particularly high risk of all types of event, including stent thrombosis, and they therefore need careful monitoring after PCI, including intense secondary prevention, as well as potent-stabilising drugs.”