Over the Long-term, EES Match CABG for Diabetic Patients With Multivessel Disease
Use of everolimus-eluting stents (EES) to treat multivessel disease in diabetic patients reduces the risk of early mortality or stroke compared with CABG, according to a study published online July 8, 2015, ahead of print in Circulation: Cardiovascular Interventions. Over the long term, the 2 therapies achieve equipoise for mortality, while EES continue to reduce stroke but are linked with more repeat procedures and—after incomplete revascularization—more MI.
The findings represent a turnaround from previous studies, notably the randomized FREEDOM trial, in which first-generation DES did not compare favorably with CABG.
For the current study, Sripal Bangalore, MD, MHA, of NYU Langone Medical Center (New York, NY), and colleagues analyzed data from 8,096 patients (mean age 64.8 years; 68% men) with diabetes and multivessel disease who underwent revascularization and were enrolled in New York State registries between 2008 and 2011.
The researchers identified 4,048 pairs of propensity-score–matched patients who received either PCI with EES or CABG.
Mortality rates favored the EES group at 30 days, though long-term rates were similar between the EES and CABG arms. EES patients also had fewer strokes at both time points, but the risks of MI and repeat revascularization were generally lower with CABG (table 1).
On subgroup analysis, however, the disparity in MI risk was lost in the subsets of patients who had 2- rather than 3-vessel disease (P = .21) or underwent complete revascularization (P = .30).
Nuances Up the Importance of Patient Preference
Because there is no added MI risk associated with EES in patients who receive complete revascularization, the choice between EES and CABG should be based on the ability to achieve that goal, the study authors say.
“FREEDOM would tell us that for patients with diabetes, all of them should undergo bypass surgery,” Dr. Bangalore told TCTMD in a telephone interview. “But now there is no longer a mortality benefit for bypass surgery. There are trade-offs.”
Moreover, the results are “largely similar” to the trends in the general population, said Dr. Bangalore, noting that multiple meta-analyses “all point to the fact that the second-generation stents are more efficacious and safer compared to the first-generation stents.”
Still, “there is no one-size-fits-all approach. You have to weigh the risks and benefits and take patients’ preferences into consideration,” he added, explaining that some patients may feel strongly about the respective risks associated with either bypass surgery or DES. “It’s a matter of having the discussion with the patient,” he said.
Bangalore S, Guo Y, Samadashvili Z, et al. Everolimus eluting stents versus coronary artery bypass graft surgery for patients with diabetes mellitus and multivessel disease. Circ Cardiovasc Interv. 2015;Epub ahead of print.
- FREEDOM: CABG Superior to PCI in Diabetic Patients with Multivessel Disease
- Early QOL Advantage of CABG Over PCI for Diabetic Patients Disappears After 2 Years
- CABG More Cost-Effective in Patients with Diabetes, Multivessel Disease Over Long Term
*Nicole Lou is the 2015 Recipient of the Jason Kahn Fellowship in Medical Journalism
- The study was funded by Abbott Vascular.
- Dr. Bangalore reports consulting for, speaking for, and receiving research funding from Abbott Vascular.