Medical Treatment and Revascularization Options in Patients With Type 2 Diabetes and Coronary Disease

• Published in: Journal of the American College of Cardiology Vol. 68; no. 10; pp. 985 - 995
• Main Authors: Mancini, G.B. John, MD, Farkouh, Michael E., MD, MSc, Brooks, Maria M., PhD, Chaitman, Bernard R., MD, Boden, William E., MD, Vlachos, Helen, MSc, Hartigan, Pamela M., PhD, Siami, Flora S., MPH, Sidhu, Mandeep S., MD, Bittner, Vera, MD, MSPH, Frye, Robert, MD, Fuster, Valentin, MD, PhD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 06.09.2016; Elsevier Limited
• Subjects: Body mass index; Cardiology; Cardiovascular; Chronic obstructive pulmonary disease; Clinical outcomes; Clinical trials; Confidence intervals; Coronary Artery Bypass; coronary artery bypass grafting; Coronary Artery Disease - complications; Coronary Artery Disease - pathology; Coronary Artery Disease - physiopathology; Coronary Artery Disease - therapy; Coronary vessels; Diabetes; Diabetes Mellitus, Type 2 - complications; Female; Heart attacks; Humans; Internal Medicine; Laboratories; Male; Middle Aged; Mortality; optimal medical therapy; Patients; Percutaneous Coronary Intervention; Prospective Studies; Randomized Controlled Trials as Topic; stable ischemic heart disease; Stents; Stratigraphy; Stroke; Stroke Volume; Time Factors; Treatment Outcome; Variables; Veins & arteries; coronary artery disease; T2DM; ejection fraction; stable ischemic heart disease; coronary artery bypass grafting; CI; optimal medical therapy; CAD; myocardial infarction; LVEF; HR; proximal left anterior descending; pLAD; percutaneous coronary intervention; OMT; PCI; hazard ratio; type 2 diabetes mellitus; confidence interval; CABG; MI; coronary artery bypass grafting
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2016.06.021

Abstract Background There are scant outcomes data in patients with type 2 diabetes and stable coronary artery disease (CAD) stratified by detailed angiographic burden of CAD or left ventricular ejection fraction (LVEF). Objectives This study determined the effect of optimal medical therapy (OMT), with or without percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), on long-term outcomes with respect to LVEF and number of diseased vessels, including proximal left anterior descending artery involvement. Methods A patient-level pooled analysis was undertaken in 3 federally-funded trials. The primary endpoint was the composite of death, myocardial infarction (MI), or stroke, adjusted for trial and randomization strategy. Results Among 5,034 subjects, 15% had LVEF <50%, 77% had multivessel CAD, and 28% had proximal left anterior descending artery involvement. During a median 4.5-year follow-up, CABG + OMT was superior to PCI + OMT for the primary endpoint (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.59 to 0.85; p = 0.0002), death (HR: 0.76; 95% CI: 0.60 to 0.96; p = 0.024), and MI (HR: 0.50; 95% CI: 0.38 to 0.67; p = 0.0001), but not stroke (HR: 1.54; 95% CI: 0.96 to 2.48; p = 0.074). CABG + OMT was also superior to OMT alone for prevention of the primary endpoint (HR: 0.79; 95% CI: 0.64 to 0.97; p = 0.022) and MI (HR: 0.55; 95% CI: 0.41 to 0.74; p = 0.0001), and was superior to PCI + OMT for the primary endpoint in patients with 3-vessel CAD (HR: 0.72; 95% CI: 0.58 to 0.89; p = 0.002) and normal LVEF (HR: 0.71; 95% CI: 0.58 to 0.87; p = 0.0012). There were no significant differences in OMT versus PCI + OMT. Conclusions CABG + OMT reduced the primary endpoint during long-term follow-up in patients with type 2 diabetes and stable CAD, supporting this as the preferred management strategy.