Background: Improved percutaneous coronary intervention (PCI) outcomes have been observed with second-generation drug eluting stents (DES). Limited evaluation of their role in comparison to coronary artery bypass graft surgery (CABG) exists in patients with diabetes and multivessel coronary artery disease.
Methods: We examined patients with diabetes and multivessel disease (≥2-vessel, non-left main) with both stable and acute presentations, revascularized within the APPROACH Registry from April 2008 to March 2016. PCI (with second-generation DES only) or CABG was considered if performed ≤ 3months from index angiogram. A cohort with similar baseline characteristics was assembled using propensity score matching technique. The primary outcome includes a composite of long-term all-cause mortality, myocardial infarction (MI), or stroke in patients surviving to 30-days following revascularization.
Results: Of 4348 patients (3115 PCI, 1233 CABG), 1233 propensity matched pairs were identified. Within 30-days, no difference in odds of mortality (adjusted OR 0.66, 95% CI 0.35-1.25) or stroke (adjusted OR 1.00, 95% CI 0.14-7.11) were observed, but higher rates of MI (adjusted OR 3.70, 95% CI 1.50 - 9.20) with PCI were noted. Over a median 3.9 year (IQR 2.0-6.0) follow-up, PCI was associated with a higher primary event rate (24.8% vs. 16.7%, adjusted HR 1.55, 95%CI 1.30-1.84), driven by higher rates of MI (10.2% vs. 2.1%, adjusted HR 5.49, 95% CI 3.56-8.47) with no difference in all-cause death (15.9% vs. 13.6%, adjusted HR 1.16, 95% CI 0.85-1.42) or stroke (3.3% vs. 3.5%, adjusted HR 0.97, 95% CI 0.63-1.51). Stratified by coronary anatomy, a significant interaction of the primary composite was observed for the presence of proximal LAD stenosis (proximal LAD ≥70%: HR 1.89, 95% CI 1.55-2.32; proximal LAD <70% HR 0.89, 95% CI 0.65-1.22, p-interaction<0.01).
Conclusion: CABG is associated with an improved long-term ischemic composite, largely driven by lower rates of recurrent MI in patients with diabetes surviving to 30-days. This appears particularly relevant for patients with significant proximal LAD disease. These considerations should be applied when contemplating a revascularization strategy in diabetics with multivessel disease.