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

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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.

Key Words

coronary artery bypass grafting
optimal medical therapy
percutaneous coronary intervention
stable ischemic heart disease

Abbreviations and Acronyms

CABG
coronary artery bypass grafting
CAD
coronary artery disease
CI
confidence interval
HR
hazard ratio
LVEF
ejection fraction
MI
myocardial infarction
OMT
optimal medical therapy
PCI
percutaneous coronary intervention
pLAD
proximal left anterior descending
T2DM
type 2 diabetes mellitus

Cited by (0)

Dr. Mancini has received honoraria from Regeneron, Merck Canada, Amgen, Sanofi, Boehringer Ingelheim, and AstraZeneca; and has served on the advisory board for Amgen and Sanofi. Dr. Brooks has received a research grant from Gilead Sciences. Dr. Chaitman has served on the speakers bureau for Gilead Sciences; has served on the advisory boards of Merck, Sanofi, Novo Nordisk, and Lilly; has served on clinical events committees for Merck, Novo Nordisk, and Lilly; and has served on the Data Safety and Monitoring Board of Sanofi. Dr. Boden has received research grants from Abbvie and Amgen; has served on the speakers bureau for Janssen, Merck, Sanofi, and Gilead Sciences; and has served on the advisory boards of Arisaph, CardioDx, Merck, and Sanofi. Ms. Siami has received a research grant from Cordis. Dr. Bittner has received research grants from Bayer Healthcare and Janssen; has received honoraria from Sanofi, Amgen, and AstraZeneca; has served on the advisory board for Lilly and Amgen; and has received a research grant from Pfizer. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Deepak Bhatt, MD, MPH, served as Guest Editor for this paper.

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