Coronary revascularization in diabetic patients: a comparison of the randomized and observational components of the Aypass Angioplasty Revascularization Investigation (BARI)

Comparison of Characteristics and Outcomes of Veterans With Stable Ischemic Heart Disease Enrolled in the COURAGE Trial Versus the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

Randomized clinical trials have not demonstrated a survival benefit with percutaneous coronary intervention in stable ischemic heart disease (SIHD). We evaluated the generalizability of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial findings to the broader population of veterans with SIHD. Veterans who underwent coronary angiography between 2005 and 2013 for SIHD were identified from the Veterans Affairs Clinical Assessment, Reporting and Tracking Program (VA CART). Patient-level comparisons were made between patients from VA CART who met the eligibility criteria for COURAGE and veterans enrolled in COURAGE between 1999 and 2004. All-cause mortality over long-term follow-up was assessed using Cox proportional hazards models. COURAGE-eligible patients from VA CART (n = 59,758) were older, had a higher body mass index, a greater prevalence of co-morbidities, but fewer diseased vessels on index coronary angiography, and were less likely to be on optimal medical therapy at baseline and on 1-year follow-up compared with VA COURAGE participants (n = 968). Patients from VA CART (median follow-up 6.5 years) had higher all-cause mortality (adjusted hazard ratio [aHR] 1.98 [1.61 to 2.43]) than participants from VA COURAGE (median follow-up: 4.6 years). Risks of mortality were greater in the 56.4% patients from CART who were medically managed (aHR 1.94 [1.49 to 2.53]) and in the 43.6% who underwent percutaneous coronary intervention (aHR 1.99 [1.45 to 2.74]), compared with their respective VA COURAGE arms. In conclusion, in this noncontemporaneous patient-level analysis, veterans in the randomized COURAGE trial had more favorable outcomes than the population of veterans with SIHD at large.

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with coronary heart disease and type 2 diabetes mellitus: Cumulative meta-analysis

Previous meta‐analyses showed that coronary artery bypass grafting (CABG) has lower all‐cause mortality than percutaneous coronary intervention (PCI) for the management of coronary heart disease (CHD), but the long‐term outcomes were not analyzed thoroughly in patients with type 2 diabetes mellitus (T2DM). To perform a meta‐analysis of randomized controlled trials (RCTs) to explore the long‐term effectiveness between CABG and PCI in patients with T2DM and study the temporal trends using a cumulative meta‐analysis. PubMed, Embase, Cochrane library, and Clinical Trials Registry for eligible RCTs published up to September 2020. The outcomes were all‐cause death, cardiac death, myocardial infarction, repeat revascularization, and stroke. Nine RCTs and 4566 patients were included. CABG resulted in better outcomes than PCI in terms of all‐cause death (RR = 1.41, 95%CI: 1.22–1.63, p < 0.001), cardiac death (RR = 1.56, 95%CI: 1.25–1.95, p < 0.001), and repeat revascularization (RR = 2.68, 95%CI: 1.86–3.85, p < 0.001), but with difference regarding the occurrence of myocardial infarction (RR = 1.20, 95%CI: 0.78–1.85, p = 0.414), while PCI was associated with better outcomes in terms of stroke occurrence (RR = 0.51, 95%CI: 0.34–0.77, p = 0.001). The cumulative meta‐analysis for all‐cause death showed that the differences between CABG and PCI started to be significant at 3 years of follow‐up, while the difference became significant at 5 years for cardiac death. In patients with CHD and T2DM, CABG results in better outcomes than PCI in terms of all‐cause death, cardiac mortality, and repeat revascularization, while PCI had better outcomes in terms of stroke. The differences are mainly observed over the long‐term follow‐up.

Coronary artery bypass grafting versus percutaneous coronary intervention in patients with noninsulin treated type 2 diabetes mellitus: A meta-analysis of randomized controlled trials

BACKGROUND

The outcomes and prognosis of revascularization by either coronary artery bypass grafting (CABG) surgery or percutaneous coronary intervention (PCI) in patients with noninsulin-treated type 2 diabetes mellitus (NITDM) have not yet been well established.

METHODS

Randomized controlled trials (RCTs) were identified by searching Pubmed, EMBASE, and Cochrane library from inception until May 2016. Heterogeneity was evaluated, and the pooled hazard ratio (HR) was calculated by using a fixed-effect model. A random-effect model was used when statistically significant heterogeneity was observed (I²  ≥ 50%). All data analyses were carried out by using RevMan 5.3 and STATA software 12.0.

RESULTS

A total of 4 RCTs involving 5 studies, consisting of 2270 patients with noninsulin-treated type 2 diabetes mellitus, were identified. Compared with CABG-treated patients, PCI-treated patients had significantly higher all-cause mortality (HR 1.39; 95% CI 1.01 to 1.91; P = .04), myocardial infarction (HR 2.14; 95% CI 1.40 to 3.27; P = .0004), repeated revascularization (HR 2.52; 95% CI 1.77 to 3.57; P < .00001), and major adverse cardiovascular and cerebrovascular events (HR 1.50; 95% CI 1.20-1.87; P = .0004). However, PCI was associated with lower incidence of stoke (HR 0.47; 95% CI 0.24 to 0.90; P = .02).

CONCLUSIONS

In NITDM patients, our study suggests that CABG surgery is associated with reduced risk of mortality and morbidity, although with increased incidence of stroke compared with percutaneous coronary intervention. The decision if to have percutaneous coronary intervention or CABG surgery should factor the risk for stroke of the patients when considering CABG over percutaneous coronary intervention. Adequately powered RCTs are needed to confirm the results of this meta-analysis.

Feasibility of visual aids for risk evaluation by hospitalized patients with coronary artery disease: results from face-to-face interviews

PURPOSE

Communicating information about risk and probability to patients is considered a difficult task. In this study, we aim to evaluate the use of visual aids representing perioperative mortality and long-term survival in the communication process for patients diagnosed with coronary artery disease at the National Institute of Cardiology, a Brazilian public hospital specializing in cardiology.

PATIENTS AND METHODS

One-on-one interviews were conducted between August 1 and November 20, 2017. Patients were asked to imagine that their doctor was seeking their input in the decision regarding which treatment represented the best option for them. Patients were required to choose between alternatives by considering only the different benefits and risks shown in each scenario, described as the proportion of patients who had died during the perioperative period and within 5 years. Each participant evaluated the same eight scenarios. We evaluated their answers in a qualitative and quantitative analysis.

RESULTS

The main findings were that all patients verbally expressed concern about perioperative mortality and that 25% did not express concern about long-term mortality. Twelve percent considered the probabilities irrelevant on the grounds that their prognosis would depend on "God's will." Ten percent of the patients disregarded the reported likelihood of perioperative mortality, deciding to focus solely on the "chance of being cured." In the quantitative analysis, the vast majority of respondents chose the "correct" alternatives, meaning that they made consistent and rational choices.

CONCLUSION

The use of visual aids to present risk attributes appeared feasible in our sample. The impact of heuristics and religious beliefs on shared health decision making needs to be explored better in future studies.

Investigating generalizability of results from a randomized controlled trial of the management of chronic widespread pain: the MUSICIAN study

Trials are rarely able to evaluate the external validity of their results. This study demonstrates differences between eligible participants/nonparticipants and quantifies the effect on results.

The generalisability of randomised controlled trials will be compromised if markers of treatment outcome also affect trial recruitment. In a large trial of chronic widespread pain, we aimed to determine the extent to which randomised participants represented eligible patients, and whether factors predicting randomisation also influenced trial outcome. Adults from 8 UK general practices were surveyed to determine eligibility for a trial of 2 interventions (exercise and cognitive behavioural therapy [CBT]). Amongst those eligible, logistic regression identified factors associated with reaching the randomisation step in the recruitment process. The main trial analysis was recomputed, weighting for the inverse of the likelihood of reaching the randomisation stage, and the numbers needed to treat were calculated for each treatment. Eight hundred eighty-four persons were identified as eligible for the trial, of whom 442 (50%) were randomised. Several factors were associated with the likelihood of reaching the randomisation stage: higher body mass index (odds ratio: 1.99; 0.85-4.61); more severe/disabling pain (1.90; 1.21-2.97); having a treatment preference (2.11; 1.48-3.00); and expressing positivity about interventions offered (exercise: 2.66; 1.95-3.62; CBT: 3.20; 2.15-4.76). Adjusting for this selection bias decreased the treatment effect associated with exercise and CBT but increased that observed for combined therapy. All were associated with changes in numbers needed to treat. This has important implications for the design and interpretation of pain trials generally.

Revascularization for Advanced Coronary Artery Disease in Type 2 Diabetic Patients: Choosing Wisely Between PCI and Surgery

PURPOSE OF REVIEW

Patients with type 2 diabetes mellitus (T2DM) are at an increased risk of systemic atherosclerosis and advanced coronary artery disease (CAD). Herein, we review clinical trials comparing surgical to percutaneous revascularization in the context of the unique pathophysiology in this patient population, and seek to answer the question of optimal strategy of revascularization.

RECENT FINDINGS

Early studies showed a signal towards benefit of surgical revascularization over percutaneous revascularization in this group, but there was a paucity of randomized clinical trials (RCT) to directly support this finding. The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM), a large-scale international RCT, was then undertaken and established the benefit of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) in terms of mortality, myocardial infarction and repeat revascularization; CABG was inferior to PCI with regards to stroke. The quality of life and cost effectiveness also demonstrated a long-term benefit for surgery. The decision as to choice of mode of revascularization in patients with T2DM and advanced CAD depends upon a multitude of factors, including the coronary anatomy, co-morbidities and the patient's surgical risk. These factors influence the recommendation of the cardiovascular team, which should result in a balanced presentation of the short and long-term risks and benefits of either mode of revascularization to the patient and his/her family.

The Italian Multiple Sclerosis Database Network (MSDN): the risk of worsening according to IFNβ exposure in multiple sclerosis

We evaluated the risk of worsening according to the length of exposure to interferon beta (IFNβ)ina large cohort of 2090 multiple sclerosis patients collected by the Italian MS Database Network. Overall 44-140 patient-visits with a follow-up of 22-143 patient-years were evaluated. Forty-one per cent of patients were exposed to IFNβ for up to 2 years, 39% for 2- 4 years and 20% for more than 4 years. A Cox regression model was used to analyse two clinical outcomes: disability progression and worsening of relapse rate. The technique of propensity score was applied to reduce bias in the comparison of non-randomized groups. The risks of disability progression (HR=0.23; 95% CI: 0.17 - 0.30) and worsening of relapse rate (HR=0.19; 95% CI: 0.14 - 0.27) were reduced by about 4- 5- fold in patients exposed to IFNβ for more than four years, compared with patients exposed for up to two years. The propensity score technique confirmed the findings. The proportion of days covered by IFNβ treatment was lower ( P<0.0001) in patients exposed to IFNβ for up to two years than in other groups. A clinical stabilization over two years of IFNβ exposure may predict a subsequent good clinical response to treatment.

Coronary artery bypass surgery compared with percutaneous coronary interventions in patients with insulin-treated type 2 diabetes mellitus: a systematic review and meta-analysis of 6 randomized controlled trials

Background

Data regarding the long-term clinical outcomes in patients with insulin-treated type 2 diabetes mellitus (ITDM) revascularized by either coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) are still controversial. We sought to compare the long-term (≥1 year) adverse clinical outcomes in patients with ITDM who underwent revascularization by either CABG or PCI.

Methods

Randomized Controlled Trials (RCTs) comparing the long-term clinical outcomes in patients with ITDM and non-ITDM revascularized by either CABG or PCI were searched from electronic databases. Data for patients with ITDM were carefully retrieved. Odd Ratio (OR) with 95 % confidence interval (CI) was used to express the pooled effect on discontinuous variables and the pooled analyses were performed with RevMan 5.3.

Results

Six RCTs involving 10 studies, with a total of 1297 patients with ITDM were analyzed (639 patients from the CABG group and 658 patients from the PCI group). CABG was associated with a significantly lower mortality rate compared to PCI with OR: 0.59, 95 % CI 0.42–0.85; P = 0.004. Major adverse cardiovascular and cerebrovascular events as well as repeated revascularization were also significantly lower in the CABG group with OR: 0.51, 95 % CI 0.27–0.99; P = 0.03 and OR 0.34, 95 % CI 0.24–0.49; P < 0.00001 respectively. However, compared to PCI, the rate of stroke was higher in the CABG group with OR: 1.41, 95 % CI 0.64–3.09; P = 0.40, but this result was not statistically significant.

Conclusion

CABG was associated with significantly lower long-term adverse clinical outcomes compared to PCI in patients with ITDM. However, due to an insignificantly higher rate of stroke in the CABG group, further researches with a larger number of randomized patients are required to completely solve this issue.

Optimal approaches to diabetic patients with multivessel disease

The pathophysiology of diabetes and systemic insulin resistance contributes to the nature of diffuse atherosclerosis and a high prevalence of multivessel coronary artery disease (CAD) in diabetic patients. The optimal approach to this patient population remains a subject of an ongoing discussion. In this review, we give an overview of the unique pathophysiology of CAD in patients with diabetes, summarize the current state of therapies available, and compare modalities of revascularization that have been investigated in recent clinical trials. We conclude by highlighting the importance of a comprehensive heart team approach to every patient while accommodating both patient preference and quality-of-life decisions.

Do current clinical trials meet society's needs?: a critical review of recent evidence

This paper describes some important controversies regarding the current state of clinical trials research in cardiology. Topics covered include the inadequacy of trial research on medical devices, problems with industry-sponsored trials, the lack of head-to-head trials of new effective treatments, the need for wiser handling of drug safety issues, the credibility (or lack thereof) of trial reports in medical journals, problems with globalization of trials, the role of personalized (stratified) medicine in trials, the need for new trials of old drugs, the need for trials of treatment withdrawal, the importance of pragmatic trials of treatment strategies, and the limitations of observational comparative effectiveness studies. All issues are illustrated by recent topical trials in cardiology. Overall, we explore the extent to which clinical trials, as currently practiced, are successful in meeting society's expectations.

Outcomes for patients with the same disease treated inside and outside of randomized trials: a systematic review and meta-analysis

BACKGROUND

It is unclear whether participation in a randomized controlled trial (RCT), irrespective of assigned treatment, is harmful or beneficial to participants. We compared outcomes for patients with the same diagnoses who did ("insiders") and did not ("outsiders") enter RCTs, without regard to the specific therapies received for their respective diagnoses.

METHODS

By searching the MEDLINE (1966-2010), Embase (1980-2010), CENTRAL (1960-2010) and PsycINFO (1880-2010) databases, we identified 147 studies that reported the health outcomes of "insiders" and a group of parallel or consecutive "outsiders" within the same time period. We prepared a narrative review and, as appropriate, meta-analyses of patients' outcomes.

RESULTS

We found no clinically or statistically significant differences in outcomes between "insiders" and "outsiders" in the 23 studies in which the experimental intervention was ineffective (standard mean difference in continuous outcomes -0.03, 95% confidence interval [CI] -0.1 to 0.04) or in the 7 studies in which the experimental intervention was effective and was received by both "insiders" and "outsiders" (mean difference 0.04, 95% CI -0.04 to 0.13). However, in 9 studies in which an effective intervention was received only by "insiders," the "outsiders" experienced significantly worse health outcomes (mean difference -0.36, 95% CI -0.61 to -0.12).

INTERPRETATION

We found no evidence to support clinically important overall harm or benefit arising from participation in RCTs. This conclusion refutes earlier claims that trial participants are at increased risk of harm.

Update on drug-eluting coronary stents

The introduction of drug-eluting stents (DES) to interventional cardiology practice has resulted in a significant improvement in the long-term efficacy of percutaneous coronary interventions. DES successfully combine mechanical benefits of bare-metal stents and stabilizing the lumen, with direct delivery and the controlled elution of a pharmacologic agent to the injured vessel wall to suppress further neointimal proliferation. The dramatic reduction in restenosis has resulted in the implementation of DES in clinical practice, and has rapidly expanded the whole spectrum of successfully treatable coronary conditions, particularly in high-risk patients and complex lesions. In this review the authors present current data on DES. Currently, two types of DES are available in the USA: sirolimus-eluting stents (SES) CYPHER (Cordis Corp., FL, USA) and paclitaxel-eluting stents (PES) TAXUS (Boston Scientific, MA, USA), and many more are on the way to approval. In addition to sirolimus and paclitaxel, several other drugs have been successfully used in DES. Everolimus and ABT-578 are both analogs of sirolimus that also have immunosuppressive and antiproliferative properties. Another approach in the development of DES is to use drugs that can accelerate re-endothelialization and restore normal endothelial function following vascular injury. Recent advances in vascular gene transfer have also demonstrated potential new treatment modalities for cardiovascular disease, particularly in the treatment of vascular restenosis.

Cost-effectiveness of percutaneous coronary intervention with drug eluting stents versus bypass surgery for patients with diabetes mellitus and multivessel coronary artery disease: results from the FREEDOM trial

BACKGROUND

Studies from the balloon angioplasty and bare metal stent eras have demonstrated that coronary artery bypass grafting (CABG) is cost-effective compared with percutaneous coronary intervention (PCI) for patients undergoing multivessel coronary revascularization-particularly among patients with complex coronary artery disease or diabetes mellitus. Whether these results apply in the drug-eluting stent (DES) era is unknown.

METHODS AND RESULTS

Between 2005 and 2010, 1900 patients with diabetes mellitus and multivessel coronary artery disease were randomized to PCI with DES (DES-PCI; n=953) or CABG (n=947). Costs were assessed from the perspective of the U.S. health care system. Health state utilities were assessed using the EuroQOL 5 dimension 3 level questionnaire. A patient-level microsimulation model based on U.S. life-tables and in-trial results was used to estimate lifetime cost-effectiveness. Although initial procedural costs were lower for CABG, total costs for the index hospitalization were $8622 higher per patient. Over the next 5 years, follow-up costs were higher with PCI, owing to more frequent repeat revascularization and higher outpatient medication costs. Nonetheless, cumulative 5-year costs remained $3641 higher per patient with CABG. Although there were only modest gains in survival with CABG during the trial period, when the in-trial results were extended to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with substantial gains in both life expectancy and quality-adjusted life expectancy and incremental cost-effectiveness ratios <$10 000 per life-year or quality-adjusted life-year gained across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs.

CONCLUSIONS

Despite higher initial costs, CABG is a highly cost-effective revascularization strategy compared with DES-PCI for patients with diabetes mellitus and multivessel coronary artery disease.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinical-trials.gov. Unique identifier: NCT00086450.

Percutaneous Coronary Intervention in Patients with Diabetes and Multivessel or Left Main Disease—A Review

Coronary artery disease in patients with diabetes is frequently a diffuse process with multivessel involvement and is associated with increased risk for myocardial infarction and death. The role of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and multivessel disease who require revascularization has been debated and remains uncertain. The debate has been continued mainly because of the question to what degree an increased risk for in-stent restenosis among patients with diabetes contributes to other late adverse outcomes. This article reviews outcomes from early trials of balloon angioplasty versus CABG through later trials of bare-metal stents versus CABG and more recent data with drug-eluting stents as the comparator. although not all studies have been powered to show statistical significance, the results have been generally consistent with a mortality benefit for caBG versus PCI, despite differential risks for restenosis with the various PCI approaches. The review also considers the impact of mammary artery grafting of the left anterior descending artery and individual case selection on these results, and proposes an algorithm for selection of patients in whom PCI remains a reasonable strategy.

Percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in the treatment of diabetic patients with multi-vessel coronary disease: a meta-analysis

Diabetes is prevalent in patients with coronary artery disease. In diabetic patients with multi-vessel coronary disease, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are widely used for revascularization. We aimed to compare the effectiveness and safety of PCI and CABG in these patients. Nine randomized controlled trials were identified in which a total of 1047 diabetic patients were randomly assigned to PCI and 1054 to CABG. Results showed that five-year mortality was significantly higher in diabetic patients after PCI than after CABG (risk difference (RD) of 7%; P<0.001); repeated revascularization was more common after PCI than after CABG (one-year RD of 13%; P<0.001); major adverse cardiac and cerebrovascular events were also more frequent after PCI (one-year RD of 12%; P<0.001); however, the cerebrovascular accident rate was lower in the PCI group than the CABG group (one-year RD of -2%; P=0.004). Conclusively, in diabetic patients with multi-vessel coronary disease, CABG was not only more effective than PCI in reducing mortality but also led to fewer repeated revascularizations and fewer major adverse cardiac and cerebrovascular events. Despite these benefits, CABG did put diabetic patients at higher risk for cerebrovascular accident than PCI.

Long-term survival of patients with ischemic cardiomyopathy treated by coronary artery bypass grafting versus medical therapy

BACKGROUND

We prospectively applied the Surgical Treatment of Ischemic Cardiomyopathy trial entry criteria to an observational database to determine whether coronary artery bypass grafting (CABG) decreases mortality compared with medical therapy (MED) for patients with coronary artery disease and depressed left ventricular ejection fraction.

METHODS

This was a retrospective, observational, cohort study of prospectively collected data from the Duke Databank for Cardiovascular Disease. Long-term mortality was the main outcome measure. Between January 1, 1995, and July 31, 2009, 86,874 patients underwent cardiac catheterization for suspected ischemic heart disease and were evaluated for inclusion in the analysis.

RESULTS

A total of 2,624 patients were found to have left ventricular ejection fraction less than 0.35, coronary artery disease amenable to CABG, and no left main stenosis of greater than 50%. After exclusions including ongoing Canadian Cardiovascular Society class III angina and acute myocardial infarction, 763 patients were included for propensity score analysis, including 624 who received MED and 139 who underwent CABG. Adjusted mortality curves were constructed for those patients in the three quintiles most likely to receive CABG. The curves diverged early, with risk-adjusted mortality rates at 5 years of 46% for MED versus 29% for CABG, and the survival benefit of CABG over MED continued through 10 years of follow-up (hazard ratio, 0.63; 95% confidence interval, 0.45 to 0.88).

CONCLUSIONS

Among a propensity-matched, risk-adjusted, observational cohort of patients with coronary artery disease, left ventricular ejection fraction less than 0.35, and no left main disease of greater than 50%, CABG is associated with a survival advantage over MED through 10 years of follow-up.

Randomized trial of insulin versus usual care in reducing restenosis after coronary intervention in patients with diabetes. the STent Restenosis And Metabolism (STREAM) study

BACKGROUND

Diabetes status is an independent marker of restenosis after percutaneous coronary intervention (PCI). Previous studies suggest that metabolic abnormalities associated with diabetes increase stent restenosis by promoting intimal hyperplasia. Preclinical studies have indicated that insulin therapy reduces intimal hyperplasia. The objective of this study was to determine whether insulin-mediated glucose lowering reduces in-stent restenosis in patients with diabetes undergoing PCIs.

METHODS

We conducted a prospective, randomized, multicenter, open-labeled study with blinded outcomes. Patients were randomized 1:1 to daily bedtime subcutaneous NPH insulin (Novo Nordisk) versus usual therapy with oral hypoglycemic agents. The main outcomes were change in volume of intimal hyperplasia within the stent measured by intravascular ultrasound and late lumen loss by quantitative coronary angiography at 6 months post-PCI.

RESULTS

Seventy-eight patients (36 insulin, 42 usual care) were randomized. Eight patients in each group received drug-eluting stents. The insulin group achieved greater reductions in both glycosylated hemoglobin A1c (mean±S.D.) (insulin: 8.0%±1.2% to 6.7%±0.7% vs. control: 7.5%±1.2% to 7.1%±1.0 %, P=.0038) and fasting glucose (insulin: 9.3±3.8 to 5.8±1.7 vs. usual care: 8.4±2.4 to 7.7±2.0 mmol/l, P<.0001). There were no hypoglycemic events. At 6 months, there were no significant differences in either intravascular-ultrasound-determined neointimal volume (insulin: 41.2±38.9 vs. usual care: 48.4±40.2 mm(3), P=.33) or late lumen loss by angiography (insulin: 1.29±0.74 mm vs. usual care: 1.02±0.71 mm, P=.17).

CONCLUSIONS

Addition of a single bedtime dose of insulin in patients with diabetes does not influence in-stent restenosis.

Extracorporeal shock wave therapy reverses ischemia-related left ventricular dysfunction and remodeling: molecular-cellular and functional assessment

An optimal treatment for patients with diffuse obstructive arterial disease unsuitable for catheter-based or surgical intervention is still pending. This study tested the hypothesis that extracorporeal shock wave (ECSW) therapy may be a therapeutic alternative under such clinical situation. Myocardial ischemia was induced in male mini-pigs through applying an ameroid constrictor over mid-left anterior descending artery (LAD). Twelve mini-pigs were equally randomized into group 1 (Constrictor over LAD only) and group 2 (Constrictor over LAD plus ECSW [800 impulses at 0.09 mJ/mm²] once 3 months after the procedure). Results showed that the parameters measured by echocardiography did not differ between two groups on days 0 and 90. However, echocardiography and left ventricular (LV) angiography showed higher LV ejection fraction and lower LV end-systolic dimension and volume in group 2 on day 180 (p<0.035). Besides, mRNA and protein expressions of CXCR4 and SDF-1α were increased in group 2 (p<0.04). Immunofluorescence staining also showed higher number of vWF-, CD31-, SDF-1α-, and CXCR4-positive cells in group 2 (all p<0.04). Moreover, immunohistochemical staining showed notably higher vessel density but lower mean fibrosis area, number of CD40-positive cells and apoptotic nuclei in group 2 (all p<0.045). Mitochondrial protein expression of oxidative stress was lower, whereas cytochrome-C was higher in group 2 (all p<0.03). Furthermore, mRNA expressions of MMP-9, Bax and caspase-3 were lower, whereas Bcl-2, eNOS, VEGF and PGC-1α were higher in group 2 (all p<0.01). In conclusion, ECSW therapy effectively reversed ischemia-elicited LV dysfunction and remodeling through enhancing angiogenesis and attenuating inflammation and oxidative stress.

Myocardial revascularization by coronary arterial bypass graft: past, present, and future

The history of coronary artery bypass graft surgery is an amazing story that evolved from a basic understanding of the etiology of coronary artery disease to highly sophisticated methods of restoring blood flow to the myocardium. Adjunctive techniques of anticoagulation, coronary artery imaging, and cardiopulmonary bypass contributed greatly to our ability to provide surgical revascularization. Today, coronary artery bypass graft surgery is the treatment of choice for many patients with complex coronary artery disease. The future will certainly bring improved results with better graft patency with less operative insult and morbidity as the final chapter in the story remains untold.

Clinical implications of the BARI 2D and COURAGE trials: the evolving role of percutaneous coronary intervention

This review outlines the evolving role of percutaneous coronary intervention (PCI) for stable angina in the context of the widely discussed Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trials. Factors outlined include defining the appropriate patient population, the clinical circumstances, and the technical aspects of the procedure to optimize clinical outcomes and minimize risk. The COURAGE Trial, as others reported earlier, reported no difference in death or myocardial infarction with PCI compared with medical therapy for stable angina. In patients with type 2 diabetes mellitus in the BARI 2D Trial, a strategy of revascularization with coronary artery bypass graft surgery (CABG) or PCI resulted in no difference in mortality compared with optimal medical therapy. However, PCI for stable angina was associated with reduced angina and improved quality of life. Procedural aspects of PCI that support its continuing role in the management of patients with stable angina include the frequent advancements in PCI technology that have further enhanced both acute and long-term success. In conclusion, the implications of these findings for clinical practice include evaluating the use of PCI for stable angina in addition to optimal medical therapy to reduce angina and improve quality of life, but individualizing care for higher risk patients with more complex coronary artery disease who were not enrolled in the COURAGE and BARI 2D trials.

Impact of diabetes on outcome in patients with non-ST-elevation myocardial infarction

BACKGROUND

Diabetes mellitus contributes to the increase of cardiovascular deaths worldwide. Despite continuous treatment evolution, patients with diabetes suffering from an acute coronary syndrome still have a high morbidity and mortality. We aimed to analyze the impact of diabetes on one-year outcome in an unselected patient population with non-ST-elevation myocardial infarction (non-STEMI).

METHODS

Retrospective analysis of 847 unselected patients with non-STEMI. We compared the baseline characteristics, treatment and outcome of patients versus those without diabetes.

RESULTS

A total of 138 patients had diabetes (16%) and 709 (84%) had no diabetes. Patients with diabetes were older, often had hypertension, hyperlipidemia, previous myocardial infarction and Killip class ≥2 on admission. Approximately 80% of both patients, with and without diabetes, underwent diagnostic coronary angiography. Multivessel disease was more present among patients with diabetes, but patients with diabetes were treated more often conservatively. At one-year follow up rates of death and major adverse cardiac events were significantly higher in patients with diabetes compared to those without diabetes (8% vs. 3%; P=0.001 and 23% vs. 14%; P=0.008, respectively). Even after adjustment for differences in baseline characteristics, diabetes remained an independent predictor of mortality (OR: 2.25; CI95%: 1.05-3.91).

CONCLUSIONS

In an unselected patient population with non-STEMI, patients with diabetes have higher risk factors on admission, less often undergo coronary revascularisation and have worse outcome at one-year follow-up. Diabetes is an independent predictor of one-year mortality in patients with non-STEMI.

Outcomes of diabetics receiving bare-metal stents versus drug-eluting stents

OBJECTIVES

We sought to determine if differences existed in in-hospital outcomes, long-term rates of target vessel revascularization (TVR), and/or long-term mortality trends between patients with diabetes mellitus undergoing percutaneous coronary intervention (PCI) with either a drug-eluting stent(s) (DES) or a bare metal stent(s) (BMS).

BACKGROUND

Short- and long-term clinical outcomes of patients with diabetes mellitus undergoing PCI with DES versus BMS remain inconsistent between randomized-controlled trials (RCTs) and observational studies.

METHODS

Data were collected prospectively on diabetics undergoing PCI with either DES or BMS from January 2000 to June 2008. Demographic information, medical histories, in-hospital outcomes, and long-term TVR and mortality trends were obtained for all patients.

RESULTS

A total of 1,319 patients were included in the study. Diabetics receiving DES had a significant reduction in index admission MACE compared to diabetics receiving BMS. Using multivariable adjustment, after a mean follow-up of 2.5 years (maximum 5 years), diabetics who received DES had a 38% decreased risk of TVR compared to diabetics with BMS [HR 0.62 (95% CI: 0.43-0.90)]; diabetics with DES had an insignificant adjusted improvement in long-term survival compared to diabetics with BMS [HR 0.72 (95% CI: 0.52-1.00)]. These long-term survival and TVR rates were confirmed using propensity scoring.

CONCLUSIONS

The use of DES when compared with BMS among diabetics undergoing PCI is associated with significant improvement in long-term TVR, with an insignificant similar trend in all-cause mortality. The long-term results of this observational study are consistent with prior RCTs after adjusting for confounding variables.

What has happened to multiple arterial grafting in coronary artery bypass grafting surgery?

Coronary artery bypass grafting (CABG) is a well-established therapy for patients with multivessel coronary artery disease, with excellent short- and medium-term results. This is best illustrated by studies comparing percutaneous coronary interventions (PCIs) with CABG surgery, where CABG continues to offer better event-free survival. However, there has been increasing concern about the long-term patency of vein grafts utilized for CABG when compared with arterial grafts. Some have suggested that revascularization with arterial grafts rather than vein grafts may result in improved outcomes following CABG. This is particularly important when one considers that graft occlusion can result in recurrence of disabling angina, rehospitalization, reintervention and death. To date, however, multiple arterial grafts have yet to become the standard approach for patients undergoing CABG. This is best exemplified by reports from large registries suggesting that the use of multiple arterial grafting is limited to approximately 10% of all patients undergoing CABG. In this article, we will provide some of the evidence outlining the risk and benefits of multiple arterial grafting, but more importantly, begin to explore why the utilization of multiple arterial grafting does not appear to be increasing significantly.

Three-vessel coronary disease in diabetics: personalized versus evidence-based revascularization strategy

A steady increase in the number of diabetic patients undergoing coronary revascularization has been recorded in recent years. The causes for this rise are found predominantly in the general demographic development of western industrialized nations, the epidemic progress and wide-spread of diabetes mellitus and changes in assignment behavior. In this article, the specific risk profile of diabetic coronary patients with three-vessel disease in percutaneous or surgical revascularization and tried and tested treatment concepts for this particularly challenging group of patients, with reference to the most recent study results will be presented. Particularly, the peculiarities of coronary heart disease in diabetic patients, the choice of revascularization method, different operative strategies for diabetic patients with coronary heart disease, and challenges faced during follow-up are discussed.

Relative spatial distributions of coronary artery bypass graft insertion and acute thrombosis: a model for protection from acute myocardial infarction

BACKGROUND

Randomized trials have demonstrated coronary artery bypass surgery (CABG) to be superior to percutaneous coronary intervention with respect to long-term mortality and morbidity from myocardial infarction within specific high-risk cohorts. The purpose of this study was to analyze the spatial distribution of coronary artery bypass graft anastomoses relative to acute thromboses in native coronary arteries. We hypothesized that insertion sites of bypass grafts are located distal to sites of acute thrombosis and consequently decrease cardiac morbidity and mortality associated with plaque rupture.

METHODS

We analyzed 168 patients with prior CABG and 208 patients with ST-segment elevation myocardial infarctions (STEMI) presenting to the Brigham and Women's Hospital who underwent coronary angiography. We constructed a spatial map of the coronary arterial bypass graft insertion sites and compared these locations to sites of acute thrombosis leading to STEMI.

RESULTS

Graft insertion sites were consistently located distal to acute thrombosis sites (left anterior descending artery median graft insertion versus median thrombosis site = 72 versus 34 mm, right coronary artery 91 versus 42 mm, left circumflex artery 44 versus 37 mm). Greater than 97% of thrombosis sites were located proximal to 75% of graft insertion sites.

CONCLUSIONS

Coronary arterial bypass grafts provide the coverage of anatomic zones at risk for STEMI. The superior performance of CABG in high risk patients may be attributed to targeting of proximal coronary locations where thrombosis risk is clustered.

Survival after percutaneous coronary intervention and coronary artery bypass grafting in a single centre

OBJECTIVES

Comparison of survival after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with coronary disease.

DESIGN

Feiring Heart Clinic treated 10 815 patients with a coronary intervention (6366 PCI, 4449 CABG) from March 1999 to December 31, 2005. Their survival status as of May 31, 2006 was ascertained through the Norwegian National Registry. Survival in PCI and CABG cohorts was compared using Cox regression and propensity analysis.

RESULTS

. Covariate adjusted survival was significantly improved by CABG compared to PCI in patients with three vessel disease with and without diabetes, with hazard ratios of 0.40 and 0.61, respectively. The difference was of borderline significance in patients with one/two vessel disease with diabetes, and no difference in survival between the strategies in patients with one/two vessel disease without diabetes. Propensity analysis supported these observations. Improved survival for the PCI cohort was observed in the last quintile of procedure times.

CONCLUSIONS

Patients with three vessel disease with or without diabetes seem to have a survival benefit with CABG compared to PCI treatment.

Prognostic heterogeneity among patients with chronic stable coronary disease: determinants of long-term mortality after treatment with percutaneous intervention

AIMS

To evaluate the risk and predictors of death in a large population of patients with stable coronary disease treated with percutaneous intervention.

METHODS AND RESULTS

The study population comprised 1,276 patients with chronic angina or silent ischaemia who underwent elective coronary angioplasty. Baseline and in-hospital mortality data were prospectively collected for all patients during the index hospitalisation. Post-discharge outcome was assessed at out-patient clinic, by review of the patients' records, or direct phone contact. Deaths were classified as cardiac and non-cardiac. Age, peripheral arterial disease, congestive heart failure with NYHA class >or= III, triple-vessel disease, and procedural success (i.e. angiographic success for all lesions in the absence of peri-procedural infarction) remained as multivariate independent predictors of death. For the entire population 4-year cumulative all-cause and cardiac mortality were respectively 5.4% and 4.1%. Four-year mortality for patients without any multivariate predictor was 2.4%, while for patients with two or more predictors the death rate was 16.3% after four years.

CONCLUSIONS

Patients with stable coronary disease undergoing percutaneous treatment have an overall low mortality rate after four years. Nevertheless, stable patients comprise a heterogeneous population in terms of risk profile, ranging from patients at very low risk of late death to individuals with a poor long-term prognosis.

Impact of drug-eluting stents among insulin-treated diabetic patients: a report from the National Heart, Lung, and Blood Institute Dynamic Registry

OBJECTIVES

This study sought to evaluate the safety and efficacy of drug-eluting stents (DES) compared with bare-metal stents (BMS) in patients with insulin- and noninsulin-treated diabetes.

BACKGROUND

Diabetes is a powerful predictor of adverse events after percutaneous coronary interventions (PCI), and insulin-treated diabetic patients have worse outcomes. The DES are efficacious among patients with diabetes; however, their safety and efficacy, compared with BMS, among insulin-treated versus noninsulin-treated diabetic patients is not well established.

METHODS

Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated 1-year outcomes of insulin-treated (n = 817) and noninsulin-treated (n = 1,749) patients with diabetes who underwent PCI with DES versus BMS.

RESULTS

The use of DES, compared with BMS, was associated with a lower risk for repeat revascularization for both noninsulin-treated patients (adjusted hazard ratio [HR] = 0.59, 95% confidence interval [CI] 0.45 to 0.76) and insulin-treated subjects (adjusted HR = 0.63, 95% CI 0.44 to 0.90). With respect to safety in the overall diabetic population, DES use was associated with a reduction of death or myocardial infarction (adjusted HR = 0.75, 95% CI 0.58 to 0.96). However, this benefit was confined to the population of noninsulin-treated patients (adjusted HR = 0.57, 95% CI 0.41 to 0.81). Among insulin-treated patients, there was no difference in death or myocardial infarction risk between DES- and BMS-treated patients (adjusted HR = 0.95, 95% CI 0.65 to 1.39).

CONCLUSIONS

Drug-eluting stents are associated with lower risk for repeat revascularization compared with BMS in treating coronary artery disease among patients with either insulin- or noninsulin-treated diabetes. In addition, DES use is not associated with any significant increased safety risk compared with BMS. These findings suggest that DES should be the preferred strategy for diabetic patients.

Three-year survival following multivessel percutaneous coronary intervention with bare-metal or drug-eluting stents in unselected patients

Drug-eluting stents (DESs) have been shown to reduce the rate of repeat revascularization compared with bare-metal stents (BMSs) after multivessel percutaneous coronary intervention in carefully selected patients. However, the long-term safety and efficacy of DESs in patients with multivessel disease outside the setting of randomized trials was unknown. Therefore, all patients undergoing multivessel percutaneous coronary intervention with BMSs, sirolimus-eluting stents (SESs), or paclitaxel-eluting stents (PESs) from January 2000 to December 2005 were investigated. The primary end point was all-cause mortality. A total of 1,720 patients were recruited in 3 consecutive sequential groups of BMS (n=701; January 2000 to April 2002), SES (n=293; April 2002 to February 2003), and PES (n=726; February 2003 to December 2005). Overall median follow-up was 1,440 days. There was improved 3-year survival in the SES group (93.7%) compared with both the BMS (86.1%) and PES groups (87.3%), which remained significant after propensity score adjustment for differences in baseline and procedural characteristics (SES vs BMS, adjusted hazard ratio 0.53, 95% confidence interval 0.30 to 0.94; SES vs PES, adjusted hazard ratio 0.49, 95% confidence interval 0.28 to 0.87). There was no difference in mortality between the PES and BMS groups. Both DES types significantly reduced the need for clinically driven target-vessel and target-lesion revascularization without an excess in myocardial infarction or stent thrombosis. In conclusion, both SESs and PESs significantly reduced the need for repeated revascularization in these patients with no excess in mortality. SESs might reduce mortality in patients undergoing multivessel percutaneous coronary intervention.

Optimal treatment of the diabetic patient with multivessel disease

Diabetes is emerging as a major source of cardiovascular morbidity and mortality. The atherosclerosis associated with diabetes has a complex etiology with even more complicated manifestations, such as multivessel and diffuse coronary disease. The optimal management of the diabetic patient with multivessel disease poses a special challenge in terms of the selection of the revascularization strategy and medical therapies. In this article, we assess the evidence accumulated to date and discuss ongoing studies that will help better inform this intricate decision-making process.

Influence of diabetes mellitus on long-term survival in systematic off-pump coronary artery bypass surgery

BACKGROUND

Diabetic patients generally present a more diffuse and calcified coronary artery disease than nondiabetic patients that can affect long-term outcome especially if an off-pump coronary artery bybass graft (OPCABG) technique is used. The aim of this study was to compare long-term results of OPCABG surgery for diabetic and nondiabetic patients.

METHODS

This is a retrospective analysis of prospectively gathered data over a 10-year period of 1,000 consecutive and systematic OPCABG patients operated on between September 1996 and April 2004. Average follow-up period was 66 +/- 28 months and was 97% complete. Overall survival as well as occurrence of major adverse cardiac events in diabetic and nondiabetic patients were specifically studied.

RESULTS

In all, 278 diabetic patients and 722 nondiabetic patients were treated. There was no difference in 30-day mortality between the two groups (p = 0.70). Diabetic patients had more postoperative acute renal insufficiency (p = 0.01) and infections (sepsis; p = 0.002), and deep sternal infections (p = 0.04) Ten-year survival (p = 0.006) and survival free of major adverse cardiac events (p = 0.02) was decreased in the diabetic group. Age (hazard ratio [HR] = 1.06), peripheral vascular disease (HR = 1.72), carotid disease (HR = 1.53), congestive heart failure (HR = 1.51), incomplete revascularization (HR = 2.37), chronic renal insufficiency (HR = 1.93), left ventricular ejection fraction (HR = 0.13), and a lesser use of multiple internal thoracic artery grafts (HR = 0.67), but not diabetes mellitus (p = 0.13) were significant determinants of long-term mortality. Similarly, peripheral vascular disease (HR = 1.92), chronic renal insufficiency (HR = 2.36), emergent operation (HR = 1.71), chronic obstructive pulmonary disease (HR = 1.76), previous percutaneous coronary intervention (HR = 1.66), left ventricular ejection fraction (HR = 0.26), ischemic mitral regurgitation (HR = 1.83), and a lesser use of multiple internal thoracic artery grafts (HR = 0.72) were determinants of decreased survival free of major adverse cardiac events but not diabetes (p = 0.2). Breaking down the major adverse cardiac events, diabetes was found an independent predictive factor of recurrent myocardial infarction (HR = 1.85) and a borderline cause of readmission for congestive heart failure (p = 0.06). Need for new revascularization was comparable for both population (p = 0.37).

CONCLUSIONS

In our series of OPCABG surgery patients, diabetic patients had a comparative operative mortality and perioperative myocardial infarction rate as nondiabetic patients. However, they had an increased prevalence of postoperative acute renal insufficiency and infections. They also had a worse outcome than nondiabetic patients, but that was mainly due to a higher prevalence of preoperative comorbidities and a lesser use of multiple internal thoracic artery grafts. However, diabetes itself was a potential risk factor for long-term occurrence of myocardial infarction and congestive heart failure.

From randomized trials to registry studies: translating data into clinical information

All clinicians face the challenge of practicing evidence-based medicine and are confronted with data from a variety of studies, ranging from prospective randomized and registry studies to retrospective analyses. Unfortunately, the data frequently provide conflicting recommendations. How then should one interpret the information so that study findings can be applied directly in patient care? To evaluate the relevance of the abundance of studies published and how they apply to an individual patient, physicians must understand subtle nuances of study design and their effect on the interpretation of the results. In this Review, we examine the strengths and weaknesses of different study designs with the aim of providing the reader with a greater understanding how best to apply study results in the clinical setting.