CABG superior to PCI for diabetic patients with multi-vessel CAD

Clement Loh Chee Hoou, Faculty of Medicine, University of New South Wales, St George Hospital, Sydney, Australia

Coronary artery disease (CAD) affects millions worldwide. In North America, nearly 700,000 people are diagnosed with multi-vessel CAD and require immediate revascularisation and of these, 200,000 are diabetic. Coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) are the two main modalities of revascularisation. The previous BARI, CARDia, TAXUS and SYNTAX randomised clinical trials offered conclusive evidence favouring CABG over PCI as the preferred method of revascularisation (1). Even with the advent of drug-eluting stents, patients who underwent PCI show a greater incidence of adverse cardiovascular and cerebrovascular outcomes at twelvemonths.

In this FREEDOM trial, Farkouh et al. (2012) sought to determine if PCI with drug-eluting stents is comparable to CABG for diabetic patients with multi-vessel CAD in a multi-centre randomised controlled trial with 1900 patients enrolled in 140 different countries. Patients were assigned to receive either PCI with drug-eluting stents or CABG. The primary outcome measure was a combination of death from any cause, myocardial infarction or stroke. All patients were treated for the control of LDL-cholesterol, systolic BP and HbA1c.

At 5 years of follow-up, the CABG group was found to have a lower incidence of the primary outcome at 18.7% as compared to the PCI group at 26.6%, a difference which was statistically significant (P=0.005). The superiority of CABG was derived from differences in rates of death from any cause (P=0.049) and myocardial infarction (P<0.001), however non-fatal stroke was more frequent in the CABG group (5.2%) than the PCI group (2.4%) (1). This is conclusive that CABG is better than PCI at treating diabetics afflicted with multi-vessel coronary disease with lower rates of death and myocardial infarction, but with a higher rate of stroke (1).

References: 

1. Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al. Strategies for multivessel revascularization in patients with diabetes. The New England journal of medicine. 2012;367(25):2375-84. Epub 2012/11/06. doi: 10.1056/NEJMoa1211585 PubMed PMID: 23121323.

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