Multivessel coronary artery disease revascularisation strategies in patients with diabetes mellitus
- Correspondence to Eric R Bates,Division of Cardiovascular Diseases, Department of Internal Medicine, CVC Cardiovascular Medicine, University of Michigan Medical Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5869, USA;
Patients with diabetes mellitus have increased rates of coronary artery disease (CAD), myocardial infarction (MI), heart failure and death. Importantly, approximately 25% of patients undergoing coronary artery revascularisation have diabetes.1 Recently, the Future Revascularisation Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease trial found coronary artery bypass graft (CABG) surgery superior to percutaneous coronary intervention (PCI) in significantly reducing rates of death and MI.2 It has been suggested that this study settles the controversy over the comparative effectiveness of CABG versus PCI for patients with diabetes and stable multivessel CAD.3 ,4 However, the optimal revascularisation strategy in this patient subgroup has been debated for years because of conflicting reports.
Early results comparing CABG with PCI in patients with diabetes came from randomised clinical trial subgroup analyses.5 Only one reported a significant survival advantage for CABG,6 but small sample size and short follow-up duration were limitations of many trials. In the Bypass Angioplasty Revascularisation Investigation (BARI) trial,6 the 353 patient subgroup with diabetes had a lower 5-year mortality rate with CABG than with balloon angioplasty (19.4% vs 34.5%, p=0.0024). In 1995, the US National Heart, Lung, and Blood Institute issued a clinical alert emphasising that finding, and supporting CABG as the revascularisation strategy of choice in patients with diabetes.7 After 10 years of follow-up, survival remained superior with CABG (57.8% vs 45.5%, p=0.025).8 Repeat 10-year revascularisation rates were 20.3% with CABG and 76.6% with PCI (p<0.001). A collaborative analysis performed on 1233 patients with diabetes included in 10 randomised trials also demonstrated a lower 5-year mortality rate with CABG compared with balloon angioplasty or bare metal stent implantation (12.3% vs 20%, HR 0.70, 95% CI 0.56 to 0.87).5
More recently, the BARI 2 Diabetes trial enrolled 2368 patients with …