Revascularization in Patients With Type 1 Diabetes

Study Questions:

What are the comparative outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with type 1 diabetes (T1D) in need of multivessel revascularization?

Methods:

The investigators included all patients with T1D who underwent a first multivessel revascularization in Sweden during 1995 to 2013. They used the SWEDEHEART register, the National Diabetes Register, and the Swedish National Patient Register to retrieve information about patient characteristics and outcomes. The authors estimated hazard ratios (HRs) adjusted for confounders with 95% confidence intervals (CIs) for all-cause and coronary heart disease (CHD) mortality, myocardial infarction (MI), repeat revascularization, stroke, and heart failure using inverse probability of treatment weighting based on propensity scores.

Results:

In total, 683 patients who underwent CABG, and 1,863 patients who underwent PCI were included. During a mean follow-up of 10.6 years, 53% of patients in the CABG group and 45% in the PCI group died. PCI, compared with CABG, was associated with a similar risk of all-cause mortality (HR, 1.14; 95% CI, 0.99-1.32), but higher risks of death from CHD (HR, 1.45; 95% CI, 1.21-1.74), MI (HR, 1.48; 95% CI, 1.23-1.84) and repeat revascularization (HR, 5.64; 95% CI, 4.67-6.82). No differences in risks of stroke or heart failure were found.

Conclusions:

The authors concluded that PCI, compared with CABG, was associated with higher rates and risks of CHD mortality, MI, and repeat revascularizations in patients with T1D needing multivessel revascularization.

Perspective:

This observational, nationwide cohort study, including all patients with T1D who underwent a first multivessel revascularization in Sweden during 1995 to 2013, reports a benefit favoring CABG over PCI, with lower rates and risks of CHD mortality, MI, and repeat revascularization, with no such differences found for all-cause mortality, stroke, and heart failure. Overall, it appears that CABG should be the preferred strategy for multivessel revascularization in patients with T1D similar to those with type 2 diabetes. However, it should be noted that there were large differences in risk at baseline between the PCI and CABG groups, and these findings should be confirmed in a randomized prospective study.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Disease, Diabetes Mellitus, Type 1, ESC2017, ESC Congress, Heart Failure, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk, Stroke


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