Coronary artery bypass grafting (CABG) is the clear preferred revascularisation method for patients with diabetes and multivessel coronary artery disease, a new review has concluded.
While percutaneous coronary intervention (PCI) is increasingly preferred for many patient groups, there is still a clear superiority in terms of mortality in patients with diabetes, a pooled analysis of 11 randomised controlled trials published in The Lancet found.
Described as the largest analysis to date, involving more than 11,500 patients randomly assigned to having stents or to CABG, the review showed that the overall five-year all-cause mortality was significantly lower after CABG (9·2%) compared to PCI (11·2%) with a hazard ratio of 1·20 for PCI.
However, in subgroup analyses, CABG only had a mortality benefit over PCI in patients with multivessel disease and diabetes (10.0% vs 15.5%). No difference in mortality was seen in patients with multivessel disease without diabetes, nor in patients with left main disease
The mortality benefit of CABG over PCI increased with increasing lesion complexity, as assessed with the SYNTAX score.
The study authors said the comparative benefits of CABG and PCI had been strongly debated, especially in light of developments in stent technology. However they emphasised that their findings remained consistent in more recent trials that included more high risk patients and with the latest stent technology.
The presence of diabetes was an important modifier, … the benefit of CABG in patients with diabetes might be attributed to more effective revascularisation of diffuse, complex coronary disease,” they said.
When other factors such as coronary complexity and operative risk were taken into account, the choice between CABG and PCI could be based on the new review findings, they suggested.
“In patients with estimated clinical equipoise, as determined by heart teams, consideration of disease type (multivessel or left main), coronary complexity, and diabetes status is crucial, because these are important treatment effect modifiers of favourable mortality after CABG versus PCI and should affect decisions on coronary revascularisation in daily practice.”
An accompanying commentary went further and said that the results of this pooled analysis should be viewed as definitive in showing the preference should be for CAGB with increasing angiographic lesion complexity.
“For patients with multivessel disease and diabetes who are clinically and angiographically suitable for either CABG or PCI, CABG is the clear choice,” it concluded.
Either CABG or PCI could be used for patients with multivessel disease without diabetes, although PCI was still the treatment of choice for patients presenting with acute myocardial infraction, it added.