Revascularization of diabetic patients with acute coronary syndromes and multivessel coronary artery

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Revascularization of diabetic patients with acute
coronary syndromes and multi-vessel coronary
artery diseaseshould CABG be the preferred
revascularization strategy?

• Hubacek J, Brownell B, Galbraith PD, Ghali WA,
  Knudtson ML, Love MP
• APPROACH University of Calgary, Calgary, AB,
  Canada
• ICONS Dalhousie University, Halifax, NS, Canada

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Revascularization in DM with ACS MV CAD
DISCLOSURE
NONE
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Revascularization in DM with ACS MV CAD
PATIENTS HISTORY
Mr. DM 58M with DM, dyslipidemia,
HTN comorbidities none Admitted NSTEACS (Hx
and dynamic ECG changes) Rx appropriate medical
therapy started Biomarkers positive TnT (1.79 µg/
L) Cardiac cath mLAD 85, pRCA 90 normal LV
function EF 55
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Revascularization in DM with ACS MV CAD
Cardiac catheterization
WHAT NEXT?
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Revascularization in DM with ACS MV CAD
ACS REVASCULARIZATION IN DIABETICS
Diabetics with ACS worse short- long- term
prognosis vs. non-DM - often multi-vessel CAD -
routine invasive strategy better than
selective FRISC II, TACTICS-TIMI
18 Revascularization in DM (PCI vs. CABG)
ongoing controversy BARI, ARTS, ERACI II, MASS
II
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Revascularization in DM with ACS MV CAD
RESEARCH QUESTION
Should surgical revascularization be preferred in
ACS patients with diabetes and multivessel
coronary artery disease (CAD) in the modern
revascularization era?
HYPOTHESIS
Diabetic patients with multivessel CAD undergoing
percutaneous coronary intervention (PCI) have
similar long-term survival compared to those
undergoing coronary artery bypass grafting (CABG).
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Revascularization in DM with ACS MV CAD
OBJECTIVES
The purpose of this study was to examine the
impact of revascularization strategy (PCI versus
CABG) on long-term survival in a large cohort of
diabetic patients with ACS and multi-vessel CAD.
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Revascularization in DM with ACS MV CAD
PATIENTS
all diabetic patients with ACS and multi-vessel
CAD between Jan 1998 - Dec 2000 from APPROACH
ICONS DEFINITIONS ACS clinical diagnosis at
the time of admission - multi-vessel CAD - gt1
stenosis gt 70 in major coronaries
OUTCOME all-cause mortality
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Revascularization in DM with ACS MV CAD
ICONS (Improving Cardiovascular Outcomes in Nova
Scotia) Prospective clinical database capturing
all admissions to Nova Scotia hospitals with a
primary diagnosis of ACS or CHF since
1997 Captures detailed information about
demographics, extent of CAD, co-morbid illnesses,
treatment and outcomes
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Revascularization in DM with ACS MV CAD
APPROACH (Alberta Provincial Project for Outcome
Assessment in Coronary Heart Disease)
Prospective population-based multi-year
inception cohort database capturing detailed
information on socio-demographic
characteristics, cardiac risk factors,
co-morbidities, disease-specific variables,
cardiac catheterization findings,
revascularization and outcomes
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Revascularization in DM with ACS MV CAD
FOLLOW UP
Minimum 5 years from index cardiac
catheterization via linkage to AB and NS Vital
Statistics databases
STATISTICS chi-square, ANOVA - baseline
characteristics Kaplan-Meier analysis
unadjusted 5-year survival Cox proportional
hazard models - risk-adjusted survival
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Revascularization in DM with ACS MV CAD
PATIENTS
n of pts ACS with cardiac
catheterization 9138 - less single vessel CAD
-3495 ACS with multi-vessel
CAD 5643 - less patients Rx medically
-1342 ACS with multi-vessel CAD
revasc. 4301 - less patients without
DM -3161 ____ DIABETICS with ACS
multi-vessel CAD 1140 undergoing
revascularization
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Revascularization in DM with ACS MV CAD
DEMOGRAPHICS
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Revascularization in DM with ACS MV CAD
ANGIOGRAPHIC FINDINGS
ABC
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Revascularization in DM with ACS MV CAD
KM 5 year survival
CABG
CABG
PCI
PCI
crude survival PCI 77.2 vs. CABG 78.0 p 0.81
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Revascularization in DM with ACS MV CAD
KM 5 year survival
CABG
PCI
Risk-adjusted HR 0.70, 95 CI 0.51 0.97
Riskadjusted HR 0.78 95 CI 0.60 1.01
Risk adjustment CHF, CRF, PVD prior CABG
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Revascularization in DM with ACS MV CAD
KM 5 year survival
PCI
CABG
Risk-adjusted HR 0.92, 95 CI 0.58 1.46
Riskadjusted HR 0.70 95 CI 0.57 0.86
Risk adjustment CHF, CRF, PVD prior CABG
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Revascularization in DM with ACS MV CAD
CONCLUSIONS
This registry-based observational study of
diabetic patients with ACS and multi-vessel CAD
suggests
- overall crude 5-year survival is similar with
PCI and CABG
- a risk-adjusted survival advantage of CABG
versus PCI in diabetic patients with 3-vessel CAD

• no difference in risk-adjusted survival between
  CABG PCI
• in diabetic patients with 2-vessel CAD

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Revascularization in DM with ACS MV CAD
LIMITATIONS

• non-randomized
• risk adjustment for measured variables only
• unable to determine
• suitability for revascularization
• completeness of revascularization
• survival beyond 5 years
• timing of revascularization from admission

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Revascularization in DM with ACS MV CAD
BACK TO PATIENT

• 58M with DM, DLP, HTN
• A NSTEMI (dynamic ECG positive TnT)
• cath mLAD pRCA critical, normal LV
  function

- until clear evidence available, ART OF
MEDICINE essential - detailed discussion with
patient - consideration for multidisciplinary
assessment
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Revascularization in DM with ACS MV CAD
THANK YOU
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Revascularization in DM with ACS MV CAD
Multi-vessel CAD without pLAD involvement
CABG (n172)
PCI (n141)
p value 0.935
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Revascularization in DM with ACS MV CAD
Multi-vessel CAD with pLAD involvement
PCI (n156)
CABG (n213)
CABG (n75)
PCI (n156)
p value 0.249
p value 0.023
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Revascularization in DM with ACS MV CAD
BARI (Bypass Angioplasty Revascularization
Investivation)
JACC 2007 49 1600 - 6
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Revascularization in DM with ACS MV CAD
BARI trial vs. registry
Circulation 1999 99 633 - 40
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Revascularization in DM with ACS MV CAD
5 years mortality CABG PCI p value ARTS
trial (n208) 6.3 3.1 NS ERACI II trial
(n133) 10.2 10.6 NS
JACC 2005 46 582 - 88
Circulation 2001 104 533 - 38
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Revascularization in DM with ACS MV CAD
MASS II The Medicine, Angioplasty, or Surgery
trial
Circulation 2006 114 I420 - I421
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Revascularization in DM with ACS MV CAD
FRISC II trial
DM (n299) ARR 9.1 RRR 0.70 (0.47-1.04)
no DM (n2157) ARR 3.2 RRR 0.74 (0.58-0.94)
Lancet 1999 354 708 - 15
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Revascularization in DM with ACS MV CAD
TACTICS TIMI 18
DM (n613) ARR 7.7 p lt 0.05
no DM (n1607) ARR 2.2 p NS
NEJM 2001 344 1879-87
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Revascularization in DM with ACS MV CAD
ongoing randomized trials PCI vs. CABG /-
medical Rx pts inclusion 1-ry EP
F/U BARI-2 DM-2 1V CAD mortality
5 years medical Rx CARDIA DM 2V CAD 1 /-
PCI composite 1 year sirolimus FREEDO
M DM 2V CAD composite 5
years sirolimus COMBAT all/ DM LM
composite 5 years sirolimus


SYNTAX all/ DM 3V CAD/ LM composite
5 years paclitaxel