FROM THE ANNALS OF INTERNAL MEDICINE
Coronary artery bypass grafting is the preferred long-term revascularization technique for diabetics, based on data from a meta-analysis published in the Annals of Internal Medicine ( 2014;161:724-32 [doi:10.7326/M14-0808]).
“With more than 1 million revascularization procedures done annually in the United States alone, assessing the risks and benefits of these techniques in this subgroup is a public health priority,” said Dr. Benny Tu of Greenslopes Private Hospital in Queensland, Australia, and his colleagues. “In particular, deciding on an optimal revascularization strategy is a crucial element of clinical decision making,” the researchers wrote.
The researchers used a Bayesian network meta-analysis to combine 40 studies from English-language publications such as PubMed, the Cochrane Central Register of Controlled Trials, Ovid, and EMBASE that took place between Jan. 1, 1990, and June 1, 2014. Each of these studies was a randomized, controlled trial comparing the effects of percutaneous coronary intervention (PCI), including PCIs with bare-metal stents (PCI-BMS) and those with drug-eluding stents (PCI-DES), with coronary artery bypass grafting (CABG) in adult diabetics with either multivessel or left main coronary artery disease.
The primary outcome combination of stroke, nonfatal MI, and all-cause mortality was 33% more likely in patients who underwent PCI (odds ratio, 1.33) as opposed to CABG. PCI also was associated with significant increase of 44% in mortality (OR, 1.44), and a 44% decrease in stroke.
“The largest advantage of CABG is in avoiding repeated revascularization,” the researchers noted; the need for repeated revascularization was 137% higher with PCI than with CABG.
Researchers extracted data relevant to study design, quality, patient characteristics, length of postprocedure follow-ups, and overall outcomes to determine which procedure proved most effective at mitigating mortality and the need for repeated revascularization. For duplicate publications, outcomes were obtained from the publication with the longest follow-up.
“This trial showed that CABG significantly decreased mortality in patients with diabetes at 5 years compared with percutaneous transluminal coronary angioplasty,” the researchers noted, adding that the findings confirm the CABG endorsement published in the 1997 Bypass Angioplasty Revascularization Investigation .
However, as techniques for both PCI and CABG have improved considerably between 1990 and 2014, the researchers advised physicians to review each option on a case-by-case basis, and to consider that PCI may in fact be the preferred option for some high-risk patients.
“Although CABG may generally be preferred, there are individual clinical situations in which PCI may be a reasonable alternative,” they wrote. “For example, it might be preferred for patients at high risk for perioperative stroke or whose long-term survival is compromised because of noncardiac factors.”
The study’s primary source of funding was the Fonds de recherche du Québec-Santé, but none of the researchers reported relevant financial disclosures.
