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Impact of Diabetes on Outcomes in Left Main Coronary Revascularization: PCI vs. CABG

25 Mar 2024
diabetes PCI vs CABG

Left main coronary artery disease (CAD) and diabetes pose significant challenges in cardiovascular care, often leading to adverse outcomes. However, the comparative long-term efficacy of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with these conditions remains unclear.

Despite efforts to address this question, previous studies have been hampered by limitations, including inadequate statistical power and inherent biases in registry-based analyses. Notably, randomized controlled trials specifically addressing this clinical scenario have been lacking.

Preliminary evidence from trials focusing on patients with multivessel disease has hinted at diabetes as a potential modifier of treatment outcomes. Notably, diabetic patients undergoing CABG appeared to experience lower 5-year mortality rates compared to those undergoing PCI, while outcomes between PCI and CABG were comparable in non-diabetic patients.

Now, leveraging data from four major randomized trials, a comprehensive study aims to elucidate the influence of diabetes on outcomes in patients with left main CAD undergoing PCI versus CABG. In a recent study published in Circulation, examined how diabetes influences outcomes in left main coronary revascularization procedures, specifically PCI versus CABG, is crucial for tailored treatment strategies.

Pooled data from four trials were analyzed, encompassing patients undergoing PCI or CABG for left main disease. Trials included were: SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease), NOBLE (PCI vs. CABG in the Treatment of Unprotected Left Main Stenosis), and EXCEL [Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization]. Patients were stratified based on diabetes status, and various outcome measures were assessed using Kaplan-Meier event rates and Cox model hazard ratios.

Among the patients included, those with diabetes exhibited higher rates of adverse events, including death, spontaneous myocardial infarction (MI), and repeat revascularization. Interestingly, while rates of all-cause mortality did not differ significantly between PCI and CABG groups, PCI was associated with lower early stroke rates. However, PCI showed higher rates of spontaneous MI and repeat revascularization, particularly among diabetic patients.

Diabetes significantly impacts outcomes in left main coronary revascularization, with higher rates of adverse events observed over 5 years. Despite similar mortality risks between PCI and CABG, PCI offers advantages in terms of early stroke prevention but carries higher risks of spontaneous MI and repeat revascularization, especially among diabetic patients. These findings underscore the importance of individualized treatment approaches in left main disease management.

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Original article: Gaba P et al. Circulation. 2024;149:00–00.

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