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CABG or Stenting for Left Main CAD in Diabetes
Study Questions:
What is the effect of diabetes in patients with left main coronary artery disease (LMCAD) treated with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG)?
Methods:
The EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial randomized patients (n = 1,905) with LMCAD and site-assessed low or intermediate CAD complexity (SYNTAX scores ≤32) 1:1 to PCI with everolimus-eluting stents versus CABG, stratified by the presence of diabetes. The primary endpoint was the rate of a composite of all-cause death, stroke, or myocardial infarction (MI) at 3 years. Outcomes were examined in patients with (n = 554) and without (n = 1,350) diabetes. Event rates were based on Kaplan-Meier estimates in time-to-first-event analyses and were compared by the log-rank test.
Results:
The 3-year composite primary endpoint was significantly higher in diabetic compared with nondiabetic patients (20.0% vs. 12.9%; p < 0.001). The rate of the 3-year primary endpoint was similar after treatment with PCI and CABG in diabetic patients (20.7% vs. 19.3%, respectively; hazard ratio [HR], 1.03; 95% confidence interval, 0.71-1.50; p = 0.87) and nondiabetic patients (12.9% vs. 12.9%, respectively; HR, 0.98; 95% CI, 0.73-1.32; p = 0.89). All-cause death at 3 years occurred in 13.6% of PCI and 9.0% of CABG patients (p = 0.046), although no significant interaction was present between diabetes status and treatment for all-cause death (p = 0.22) or other endpoints, including the 3-year primary endpoint (p = 0.82) or the major secondary endpoints of death, MI, or stroke at 30 days (p = 0.61) or death, MI, stroke, or ischemia-driven revascularization at 3 years (p = 0.65).
Conclusions:
The authors concluded that the relative 30-day and 3-year outcomes of PCI with everolimus-eluting stents versus CABG were consistent in diabetic and nondiabetic patients with LMCAD and site-assessed low or intermediate SYNTAX scores.
Perspective:
This prespecified EXCEL substudy reports that compared with nondiabetic patients, diabetic patients with LMCAD were at a nearly twofold higher risk for all-cause death, stroke, or MI at 3 years. However, there was no significant difference in the 3-year composite primary endpoint of death, stroke, or MI or the powered 3-year secondary endpoint of death, stroke, MI, or ischemia-driven revascularization after PCI or CABG either in the diabetic or nondiabetic strata. These data suggest that diabetic patients with LMCAD and relatively noncomplex coronary anatomy may be potential candidates for PCI, whereas CABG should be considered for diabetic patients with more complex CAD with individual treatment decisions made with input from a multidisciplinary heart team.
Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Drug-Eluting Stents, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Secondary Prevention, Stroke, Vascular Diseases
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