Clinical study: interventional cardiology
Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study

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Abstract

OBJECTIVES

We sought to assess survival among patients with diabetes and multivessel coronary artery disease (MVD) after percutaneous coronary intervention (PCI) and after coronary artery bypass grafting surgery (CABG).

BACKGROUND

The Bypass Angioplasty Revascularization Investigation (BARI) demonstrated that diabetics with MVD survive longer after initial CABG than after initial PCI. Other randomized trials or observational databases have not conclusively reproduced this result.

METHODS

A large, regional database was linked to the National Death Index to assess five-year mortality. Of 7,159 consecutive patients with diabetes who underwent coronary revascularization in northern New England during 1992 to 1996, 2,766 (38.6%) were similar to those randomized in the BARI trial. Percutaneous coronary intervention was the initial revascularization strategy in 736 patients and CABG in 2,030. Cox proportional hazards regression was used to calculate risk-adjusted hazard ratios (HR) and 95% confidence intervals (CI 95%).

RESULTS

Patients who underwent PCI were younger, had higher ejection fractions and less extensive coronary disease. After adjusting for differences in baseline clinical characteristics, patients with diabetes treated with PCI had significantly greater mortality relative to those undergoing CABG (HR = 1.49; CI 95%: 1.02 to 2.17; p = 0.037). Mortality risk tended to increase more among 1,251 patients with 3VD (HR = 2.02; CI 95%: 1.04 to 3.91; p = 0.038) than among 1,515 patients with 2VD (HR = 1.33; CI 95%: 0.84 to 2.1; p = 0.21).

CONCLUSIONS

In this analysis of a large regional contemporary database of patients with diabetes selected to be similar to those enrolled in the BARI trial, five-year mortality was significantly increased after initial PCI. This supports the BARI conclusion on initial revascularization of patients with diabetes and MVD.

Abbreviations

BARI
Bypass Angioplasty Revascularization Investigation
CABG
coronary artery bypass grafting
CABRI
Coronary Angioplasty versus Bypass Revascularization Investigation
CHF
congestive heart failure
CI 95%
95% confidence interval
COPD
chronic obstructive pulmonary disease
EAST
Emory Angioplasty versus Surgery Trial
HR
hazard ratio
MAHI
Mid America Heart Institute
MI
myocardial infarction
MVD
multivessel coronary artery disease
NHLBI
National Heart, Lung and Blood Institute
PCI
percutaneous coronary intervention
PTCA
percutaneous transluminal coronary angioplasty
PVD
peripheral vascular disease
RITA
Randomized Intervention Treatment of Angina
2VD
two-vessel coronary artery disease
3VD
three-vessel coronary artery disease

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Supported, in part, by a grant from the American Heart Association (9970047N), September 19, 2000.