Abstract
Background
The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-Vessel Disease (FREEDOM) trial randomized only a minority of screened patients with diabetes mellitus (DM) and 2-3 vessel disease (MVD), representing an high risk diabetic MVD cohort.
Methods
Consecutive patients with DM underwent angiographic screening from June 2006 to March 2010 at Liverpool Hospital, Sydney, Australia, for the FREEDOM trial; SYNTAX Scores (SS) were subsequently performed. Patients had late follow-up to determine late rates of death, non-fatal MI and stroke.
Results
Among 1263 patients with DM 833 (66%) had 0-1 vessel disease and 430 (34%) had MVD of whom 139 had prior coronary artery bypass grafting (CABG), and SS were 0 in 272, 1-9 in 336, 10-22 in 264, 23-32 in 109, and 271 patients had SS ≥33. Revascularisation was performed by coronary artery bypass grafting (CABG) in 139 (11%), 486 (38%) underwent PCI, and 638 (51%) did not undergo a revascularization procedure; respective mean ages were 63.5, 64.2 and 64.7 years; p = 0.39, and presentation rates with an ACS were 52%, 57% and 37%; p < 0.05. Amongst patients with MVD, those undergoing CABG had lower rates of MACE than either PCI or medical therapy (22%, 40%, and 51% respectively; p < 0.001). Kaplan-Meier curves (Figure) with respect to SS and late events are shown for: A) Death; B) Non-fatal MI; C) Death/MI/Stroke; D) Late Revascularization. Multi-variable analyses found independent predictors of late mortality were age >75 (HR 6.2), prior MI (HR 1.1), prior CABG (HR 1.6); and LVEF <40% (all p < 0.05). Predictors of late MI were older age, ACS presentation at screening, LVEF < 40% and insulin use.
Conclusions
Among diabetic patients who screened for the FREEDOM Trial, among 34% with MVD CABG was associated with lower rates of non-fatal MI and MACE compared to PCI and medical therapy. The poorest outcomes were observed in DM patients with MVD managed with medical therapy alone.
Abstract P187 Figure. SYNTAX scores &late events in diabetics
Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus