Percutaneous coronary intervention versus bypass surgery as revascularization modality

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The Bypass Angioplasty Revascularization Investigation (BARI), reported that in diabetic patients who had symptomatic multi-vessel disease, CABG resulted in a significantly better outcome compared with PCI at 5 years [5] and at 7 years [6]. Among treated diabetic patients, 5-year survival was 80.6% for the CABG group and 65.5% for the percutaneous transluminal coronary angioplasty (PTCA) group (P = 0.003). The benefit was confined largely to patients who

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had more severe multi-vessel disease and those who received left internal mammary artery (LIMA) bypass grafts; no benefit was seen in patients who received only saphenous vein grafts. In the BARI registry, with revascularization modality primarily based on physician judgement, the all-cause mortality was 14.4% for PTCA versus 14.9% for CABG (P = 0.86; relative risk [RR] = 1.10), with corresponding cardiac mortality rates of 7.5% and 6.0%, respectively (P = 0.73; RR = 1.07) [7]. The higher mortality with PCI in diabetics was confirmed in the 8-year follow-up of the Emory Angioplasty versus Surgery Trial (EAST) [8] and Coronary Angioplasty versus Bypass Revascular-ization Investigation (CABRI Trial) [9]. In the EAST trial there were 59 treated diabetic pa-tients—30 in the surgical group and 29 in the angioplasty group. At 3 years, the survival was similar (surgery 90%, angioplasty 93.1%); this also was similar to the patients without treated diabetes. In the extended follow-up, after 5 years the curves began to diverge; by 8 years, there was a trend toward improved survival with CABG in the diabetic group (surgical survival 75.5%, an-gioplasty 60.1%, P = 0.23) [8]. In the CABRI population, diabetics who were randomized to PCI and those who were randomized to CABG had higher mortality than respective nondiabetics. Among diabetics, there was a strong trend toward higher mortality with PCI compared with CABG (RR, 1.81; 95% confidence interval [CI], 0.804.08) [9]. In the Mid America Heart Institute single-center registry of diabetic patients who underwent revascularization, freedom from death (30% versus 37%; P = 0.08), myocardial infarction, and subsequent revascularization during long-term follow-up was superior with CABG





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