Introducing the number one enemy of PCI: diabetes

About 25% of patients with multivessel disease undergoing myocardial revascularization surgery or PCI have diabetes.

In this subgroup, the benefit of surgery in terms of mortality has long been shown: in the BARI study (Bypass Angioplasty Revascularization Investigation) patients undergoing PCI had close to double the mortality rate at 5 years compared to those undergoing surgery, and in the more recent FREEDOM study (Future Revascularization Evaluation in Patients with Diabetes Mellitus) a reduction of combined events was also observed in favor of surgery. Finally, the diabetic patient subgroup of the SYNTAX (Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) also benefited from surgery with lower mortality.

Given all this evidence, guidelines recommend surgery to treat diabetic patients with multivessel disease. The problem is not all diabetics are the same and the vast majority of patients enrolled in previous studies had diabetes type 2.

Read also: “Additional Benefit from Radial Artery Graft in Myocardial Revascularization Surgery”.

Diabetes type can be relevant, bearing in mind that diabetes type 1 has relatively bad prognosis post-surgery. Instead, patients with type 2 diabetes have a prognosis post-surgery fairly similar to that of non-diabetic patients.

This study intended to study type 1 diabetics with multivessel disease to find the best revascularization strategy for this group of patients.

It included 683 type 1 diabetes with multivessel disease undergoing PCI or CABG with a 10.6 year follow up. This population was taken from the SWEDEHEART registry.

Read Also: “CLOSE Trial: Patients with PFO with high flow or associated with interatrial septal aneurysm receiving closure device experience lower rates of recurrent stroke”.

In this period, 53% of patients in the surgery group and 45% in the PCI group had died, thus death resulting similar in both groups. However, when looking at coronary death, AMI and new revascularization, there was a clear benefit in favor of surgery.

Conclusion

Myocardial revascularization surgery showed benefits in terms of coronary death, acute myocardial infarction and repeat revascularization in diabetes type 1 patients with multivessel disease.

Editorial Comment

The observational nature of this study is its greatest limitation, since there is a significant difference between patients undergoing one or the other revascularization strategy (regardless adjustments). Many patients in the PCI group were too sick to go to surgery, which was seen in the prior rates of stroke, cardiac failure, active cancer, and terminal kidney failure, among others.

Despite its limitations, this is the biggest cohort of type 1 diabetics with multivessel disease followed for more than 10 years, which is why surgery will continue to be the gold standard for this patients in years to come.  

Original title: PCI Versus CABG in Patients with Type 1 Diabetes and Multivessel Disease.

Reference: Thomas Nyström et al. J Am Coll Cardiol 2017. Article in press.

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