ESC 2017: CABG is the “preferred strategy” for multivessel revascularisation in patients with type 1 diabetes

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Data from a nationwide observational cohort study indicate that coronary artery bypass grafting (CABG) should be used instead of percutaneous coronary intervention (PCI) to revascularise patients with multivessel disease and type 1 diabetes. The study found that PCI was associated with a five-fold increased risk of repeat revascularisation compared with CABG in this patient cohort.

Martin J Holzmann (Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden), during his presentation of the study at the European Society of Cardiology (ESC) congress (26–30 August, Barcelona, Spain), noted that data for revascularisation strategies for patients with type 1 diabetes and multivessel disease was sparse. He explained that although previous studies had suggested that CABG was the preferred strategy for patients with multivessel disease and diabetes, these studies did not subgroup patients into type 1 or type 2 diabetes. “Because 90% of patients with diabetes have type 2 diabetes, results from these prior studies may not be generalisable to patients with type 1 diabetes in need of multivessel revascularisation,” Holzmann added.

In the present study, Holzmann and colleagues reviewed outcome data from several Swedish registries (including SWEDEHEART) to determine if patients with type 1 diabetes and multivessel disease would benefit from undergoing CABG rather than PCI. They found that, between 1995 and 2013, 683 such patients had undergone CABG and 1,863 had undergone PCI. Holzmann reported that there had been a “sharp decline” in the use of CABG over this time period—58% of patients underwent CABG between 1995 and 2000, dropping to 21% between 2001 and 2006 and further dropping to 5% between 2007 and 2013.

During 10.6 years of follow-up, there were no significant differences (after adjustment) in the rate of all-cause mortality, stroke or heart failure between those who underwent CABG and those who underwent PCI. However, patients who underwent PCI had a 45% higher risk of cardiac-specific mortality and a 47% higher risk of myocardial infarction compared with those who underwent CABG. Also, Holzmann stated: “After adjustment, patients in the PCI group had a five-fold higher risk of repeat revascularisation.”

He concluded: “Our findings indicate that for patients with type 1 diabetes CABG instead of PCI should be the preferred revascularisation strategy for multivessel revascularisation.”

Given that the study was from 1995 to 2013, both bare metal stents and drug-eluting stents (including first-generation) would have been used in the PCI procedures reviewed. However, according to Holzmann, the type of stent used “probably had nothing to do” with the worse outcomes seen with PCI. He told Cardiovascular News that the better outcome associated with CABG were because “the procedure is superior and probably will continue to be superior no matter what kind of technical advances there are in the PCI field”. However, he added that PCI should be the preferred strategy, in type 1 diabetes patients with multivessel disease, when the “immediate risk of death postoperatively is very high”, nothing that this is the case already.

To coincide with its presentation at the ESC congress, the study was simultaneously published in the Journal of the American College of Cardiology.

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