ESC Focus on Interventions & PC - 11

ESC Congress 2017

Late-Breaking Science

In Review

Interventions &
Peripheral Circulation

CABG Better Than PCI in Patients
With Type 1 Diabetes
Written by Nicola Parry

Patients who underwent CABG were younger than
those who underwent PCI (57 vs 61 years). They were
less likely to be female (37% vs 41%), to have experienced acute MI within 14 days (14% vs 37%), and to have
experienced a previous episode of stroke (7% vs 10%).
However, they were more likely to have disease in 3 vessels.
Through a mean follow-up of 10.6 years, there were no
significant differences between the groups in the risk of
all-cause mortality (adjusted HR, 1.14; 95% CI, 0.99 to 1.32).
However, compared with CABG patients, PCI patients
had a 45% higher risk of cardiac-specific death (adjusted HR, 1.45; 95% CI, 1.21 to 1.74; Figure 1) and a 47%
higher risk of MI (adjusted HR, 1.47; 95% CI, 1.23 to 1.78).
PCI patients also had a 5-fold greater risk of repeat vascularisation (adjusted HR, 5.64; 95% CI, 4.67 to 6.82).
Figure 1. Cardiac-Specific Death in T1DM Patients Undergoing CABG
vs PCI

1.0

Cumulative Incidence of Fatal CHD

Martin J. Holzmann, MD, PhD, Karolinska University
Hospital, Stockholm, Sweden, presented results from
an observational cohort study in patients with type 1
diabetes mellitus (T1DM) with multivessel disease, demonstrating that the long-term risks of cardiac death,
myocardial infarction (MI), and repeat revascularisation
were significantly higher in patients who underwent
percutaneous coronary intervention (PCI) than in those
who underwent coronary artery bypass grafting (CABG)
[Nyström T et al. J Am Coll Cardiol. 2017].
Based on data from randomised controlled trials
(RCTs) current guidelines recommend CABG as the preferred strategy of revascularisation compared with PCI in
patients with diabetes and multivessel disease. Data from
a recent meta-analysis of these studies showed a 33%
relative risk reduction for all-cause mortality at 5 years in
patients with diabetes and multivessel disease who underwent CABG compared with PCI [Verma S et al. Lancet
Diabetes Endocrinol. 2013].
Although none of those RCTs involved subgroup analyses based on diabetes type, Dr Holzmann noted that
T1DM patients are more likely to die after CABG than
those with type 2 diabetes (T2DM). Indeed, after CABG,
he stressed that T2DM patients have a similar prognosis
to that of patients without diabetes who undergo CABG.
And because most patients with diabetes have T2DM,
the findings from these studies may not be generalisable to those with T1DM.
Dr Holzmann and colleagues therefore aimed to determine whether T1DM patients with multivessel disease
might benefit from CABG instead of PCI.
Using data from the SWEDEHEART registry and other
Swedish national registries, the researchers conducted an observational cohort study that included 2,546
patients with T1DM and multivessel (≥2 vessels) disease
who underwent revascularisation (n = 1,863 for PCI, n = 683
for CABG) between 1995 and 2013 in Sweden.
The primary outcome was all-cause mortality.
Secondary outcomes were cardiac-specific mortality,
MI, heart failure, stroke, and repeat revascularisation.
Researchers found a sharp decline in the proportion
of patients undergoing CABG compared with PCI during
the study period. From 1995 to 2000, 58% of patients
underwent CABG, but this decreased to 21% from 2001
to 2006, and to only 5% from 2007 to 2013.

Treatment
CABG
PCI

0.8

0.6

0.4

0.2

0.0
1863 1770 1627 1461 1322 1170 1052 920 781 661 546 442 354 261 198 134 86
683 678 674 668 654 631 612 598 561 526 498 456 412 350 282 220 156
0

Time (Years)

Reprinted from Nyström T, Sartipy U, Franzén S, et al. PCI Versus CABG in Patients
With Type 1 Diabetes and Multivessel Disease. J Am College of Cardiol. Aug 2017.
DOI: 10.1016/j.jacc.2017.07.744, with permission from the American College of
Cardiology.

There were no differences in the long-term risks of
stroke or HF between the 2 groups.
The results of this study indicate that among patients
with T1DM and multivessel coronary artery disease,
CABG, not PCI, should be the preferred strategy for revascularisation.

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