PCI vs. CABG in Left Main Disease and Diabetes Status

Mar 15, 2024
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Authors:
Gaba P, Sabik JF, Murphy SA, et al.
Citation:
Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Left Main Disease With or Without Diabetes: Findings From a Pooled Analysis of 4 Randomized Clinical Trials. Circulation 2024;Mar 11:[Epub ahead of print].
Summary By:
Debabrata Mukherjee, MD, FACC

Quick Takes

  • Patients with diabetes undergoing revascularization had higher 5-year rates of all-cause death, spontaneous MI, repeat revascularization, and stroke compared to those without diabetes.
  • Of note, the risk of cardiovascular death tended to be higher with PCI in patients with diabetes and high SYNTAX scores.
  • PCI resulted in lower rates of early stroke compared with CABG but higher rates of spontaneous MI and repeat revascularization, with greater absolute risk excesses in later follow-up, particularly among patients with diabetes.

Study Questions:

What are the outcomes in patients with left main disease with and without diabetes undergoing percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG)?

Methods:

The investigators pooled individual patient data from four trials (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]) that randomized patients with left main disease to PCI or CABG. Patients were considered suitable for either approach. Patients were categorized by diabetes status. Kaplan-Meier event rates, Cox model hazard ratios (HRs), and interactions were assessed.

Results:

Among 4,393 patients, 1,104 (25.1%) had diabetes. Patients with diabetes experienced higher rates of 5-year death (158/1,104 [Kaplan-Meier rate, 14.7%] vs. 297/3,289 [9.3%]; p < 0.001), spontaneous myocardial infarction (MI; 67/1,104 [6.7%] vs. 114/3,289 [3.7%]; p < 0.001), and repeat revascularization (189/1,104 [18.5%] vs. 410/3,289 [13.2%]; p < 0.001). Rates of all-cause mortality did not differ after PCI versus CABG in those with (84/563 [15.3%] vs. 74/541 [14.1%]; HR, 1.11 [95% CI, 0.82–1.52]) or without (155/1,634 [9.7%] vs. 142/1,655 [8.9%]; HR, 1.08 [95% CI, 0.86–1.36; PintHR = 0.87) diabetes. Rates of stroke within 1 year were lower with PCI versus CABG in the entire population, with no heterogeneity based on diabetes status (PintHR = 0.51). The 5-year rates of spontaneous MI and repeat coronary revascularization were higher after PCI regardless of diabetes status (spontaneous MI: 45/563 [8.9%] vs. 22/541 [4.4%] in diabetes and 82/1,634 [5.3%] vs. 32/1,655 [2.1%] in no diabetes, PintHR = 0.47; repeat revascularization: 127/563 [24.5%] vs. 62/541 [12.4%] in diabetes and 254/1,634 [16.3%] vs. 156/1,655 [10.1%] in no diabetes, PintHR = 0.18). For spontaneous MI and repeat revascularization, there were greater absolute excess risks beyond 1 year in patients with diabetes (4.9% and 9.9%) compared with those without (2.1% and 4.3%; PintARD = 0.047 and 0.016).

Conclusions:

The authors report that compared with CABG, PCI resulted in no difference in the risk of death, a lower risk of early stroke regardless of diabetes status, and a higher risk of spontaneous MI and repeat coronary revascularization, with larger late absolute excess risks in patients with diabetes.

Perspective:

This analysis of patients undergoing revascularization for left main disease reports that patients with diabetes had higher 5-year rates of all-cause death, spontaneous MI, repeat revascularization, and stroke. Of note, the risk of cardiovascular death tended to be higher with PCI in patients with diabetes and high SYNTAX scores. Furthermore, PCI resulted in lower rates of early stroke compared with CABG but higher rates of spontaneous MI and repeat revascularization, with greater absolute risk excesses in later follow-up, particularly among patients with diabetes. Overall, these data support a Class IA recommendation in the 2021 ACC/AHA revascularization guidelines that state, for patients with diabetes and multivessel coronary artery disease with the involvement of the left anterior descending artery (LAD), CABG (with a left anterior mammary artery to the LAD) is recommended in preference to PCI to reduce mortality and repeat revascularizations.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Coronary Artery Bypass, Percutaneous Coronary Intervention


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