Revascularization Trends in Patients With Diabetes and Multivessel Disease With NSTEMI

May 11, 2016
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Authors:
Pandey A, McGuire DK, de Lemos JA, et al.
Citation:
Revascularization Trends in Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease Presenting With Non–ST Elevation Myocardial Infarction: Insights From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry–Get with the Guidelines (NCDR ACTION Registry–GWTG). Circ Cardiovasc Qual Outcomes 2016;May 10:[Epub ahead of print].
Summary By:
Debabrata Mukherjee, MD, FACC

Study Questions:

What are the revascularization patterns among patients with diabetes mellitus (DM) and multivessel coronary artery disease (CAD) in the setting of non–ST-segment elevation myocardial infarction (NSTEMI)?

Methods:

Using the ACTION Registry–GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get with the Guidelines), the authors compared the in-hospital use of different revascularization strategies (percutaneous coronary intervention [PCI] vs. coronary artery bypass grafting [CABG] vs. no revascularization) in DM patients with NSTEMI who had angiography, demonstrating multivessel CAD between July 2008 and December 2014. Factors associated with use of CABG versus PCI were identified using logistic multivariable regression analyses.

Results:

A total of 29,769 patients from 539 hospitals were included in the study, of which 10,852 (36.4%) were treated with CABG, 13,760 (46.2%) were treated with PCI, and 5,157 (17.3%) were treated without revascularization. The overall use of revascularization increased over the study period, with an increase in the proportion undergoing PCI (45%-48.9%; ptrend = 0.0002), and no change in the proportion undergoing CABG (36.1%-34.7%; ptrend = 0.88). There was significant variability between participating hospitals in the use of PCI and CABG (range: 22%-100%; 0%-78%, respectively; p value < 0.0001 for both). Patient-level, but not hospital-level, characteristics were statistically associated with the use of PCI versus CABG, including anatomic severity of the disease, early treatment of adenosine diphosphate receptor antagonists at presentation, older age, female sex, and history of heart failure.

Conclusions:

The authors concluded that among patients with DM and multivessel CAD presenting with NSTEMI, only one third undergo CABG during the index admission.

Perspective:

This study reports that only one third of DM patients with NSTEMI and multivessel CAD undergo CABG during index hospitalization. PCI use appears to have increased modestly over time in such patients, with no change in the proportion undergoing CABG. Furthermore, there are marked variations in the proportional use of CABG and PCI among participating hospitals, which persist even among angiographic subgroups. This suggests that local practice patterns may play an important role in the selection of revascularization strategy in NSTEMI patients with DM and multivessel CAD. Future studies are needed to better understand and optimize the decision-making process for revascularization strategies among these high-risk patients.

Keywords: ACTION Registry, Acute Coronary Syndrome, Angiography, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention


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