Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial
Selected in European Journal of Cardio-Thoracic Surgery by Rylski
Kappetein AP, Head SJ, Morice MC, Banning AP, Serruys PW, Mohr FW, Dawkins KD, Mack MJ
Eur J Cardiothorac Surg 2013;43:849-55
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This study evaluates the impact of diabetes on 5-year outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in SYNTAX-trial patients with left main coronary disease and/or three-vessel disease.
- Major adverse cardiac or cerebrovascular events (MACCE) rates were higher in diabetic patients who underwent PCI (PCI: 47% vs. CABG: 29%, p<0.001).
- The need for repeat revascularisation was higher in diabetic PCI patients (PCI: 35% vs. CABG: 15%, p<0.001).
- In non-diabetic patients, the MACCE rates and need for repeat revascularisation were also higher in PCI patients, but not so pronounced (PCI: 34% vs. CABG: 26%, p=0.002; PCI: 23% vs. CABG: 13%, p<0.001, respectively).
- Cardiac death in 5-year follow-up was significantly more frequent in patients treated with PCI than those who underwent CABG, in non-diabetics (HR=1.62, 95% CI 1.03-2.55; p=0.035) and diabetics (HR=2.01, 95% CI 1.04-3.88), p=0.034).
This sub-study of the SYNTAX trial shows that in both diabetic and non-diabetic patients, PCI resulted in higher rates of MACCE, cardiac death and repeat revascularisation at 5 years. The authors concluded "although PCI is a potential treatment option in patients with less-complex lesions, CABG should be the revascularisation option of choice for patients with more-complex anatomic disease, particularly with concurrent diabetes".
This study demonstrates that we can achieve the best results in treating our patients, only if cardiac surgeons and interventional cardiologists work together in one multidisciplinary Heart Team. The take-home message is that CABG should remain the gold standard for patients with complex coronary artery disease, especially for those with diabetes.