Outcome of coronary bypass surgery versus coronary angioplasty in diabetic patients with multivessel coronary artery disease

Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia 30322, USA. bill@hp3.eushc.org

OBJECTIVES: This study sought to compare the outcome of percutaneous transluminal coronary angioplasty (PTCA) (n = 834) and coronary artery bypass graft surgery (CABG) (n = 1805) in diabetic patients with multivessel coronary disease from an observational database. BACKGROUND: There is concern about selection of revascularization in diabetic patients with multivessel coronary artery disease. METHODS: Data were collected prospectively and entered into a computerized database. Follow-up was by letter or telephone or additional events resulting in readmission. RESULTS: After CABG there were more in-hospital deaths (0.36% vs. 4.99%, p < 0.0001) and a trend toward more Q wave myocardial infarctions than after PTCA. Five- and 10-year survival rates were 78% and 45% after PTCA and 76% and 48% after CABG, respectively (p = 0.47). At 5 and 10 years, insulin-requiring patients had lower survival rates of 72% and 31% after PTCA and 70% and 48% after CABG, respectively (p = 0.54). Multivariate correlates of long-term mortality were older age, low left ventricular ejection fraction, heart failure and hypertension. In the total group, insulin requirement was a correlate of long-term mortality. For the total group, choice of therapy had a multivariate hazard ratio close to 1. In the insulin-requiring subgroup, the multivariate hazard ratio was 1.35 (95% confidence interval 1.01 to 1.79) for PTCA versus CABG. Corrected for baseline differences, 5- and 10-year survival rates were 68% and 36% after PTCA and 75% and 47% after CABG, respectively, in the insulin-requiring subgroup. Nonfatal events were more common after PTCA, especially additional revascularization. CONCLUSIONS: This study reveals a high incidence of events in diabetic patients and raises further questions about angioplasty in insulin-requiring diabetic patients with multivessel disease.

This article has been cited by other articles:

				B. Marcheix, F. Vanden Eynden, P. Demers, D. Bouchard, and R. Cartier Influence of diabetes mellitus on long-term survival in systematic off-pump coronary artery bypass surgery. Ann. Thorac. Surg., October 1, 2008; 86(4): 1181 - 1188. [Abstract] [Full Text] [PDF]

				D. M. Bravata, A. L. Gienger, K. M. McDonald, V. Sundaram, M. V. Perez, R. Varghese, J. R. Kapoor, R. Ardehali, D. K. Owens, and M. A. Hlatky Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery Ann Intern Med, November 20, 2007; 147(10): 703 - 716. [Abstract] [Full Text] [PDF]

				S. Mohammadi, F. Dagenais, P. Mathieu, J. G. Kingma, D. Doyle, S. Lopez, R. Baillot, J. Perron, E. Charbonneau, E. Dumont, et al. Long-Term Impact of Diabetes and Its Comorbidities in Patients Undergoing Isolated Primary Coronary Artery Bypass Graft Surgery Circulation, September 11, 2007; 116(11_suppl): I-220 - I-225. [Abstract] [Full Text] [PDF]

				J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): e1 - e157. [Full Text] [PDF]

				J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): 652 - 726. [Full Text] [PDF]

				Y. Ben-Gal, Y. Moshkovitz, N. Nesher, G. Uretzky, R. Braunstein, A. Hendler, E. Zivi, I. Herz, and R. Mohr Drug-Eluting Stents Versus Coronary Artery Bypass Grafting in Patients with Diabetes Mellitus Ann. Thorac. Surg., November 1, 2006; 82(5): 1692 - 1697. [Abstract] [Full Text] [PDF]

				P. R. Soares, W. A. Hueb, P. A. Lemos, N. Lopes, E. E. Martinez, L. A.M. Cesar, S. A. Oliveira, and J. A.F. Ramires Coronary Revascularization (Surgical or Percutaneous) Decreases Mortality After the First Year in Diabetic Subjects but not in Nondiabetic Subjects With Multivessel Disease: An Analysis From the Medicine, Angioplasty, or Surgery Study (MASS II) Circulation, July 4, 2006; 114(1_suppl): I-420 - I-424. [Abstract] [Full Text] [PDF]

				R. E. Gilbert, K. Connelly, D. J. Kelly, C. A. Pollock, and H. Krum Heart Failure and Nephropathy: Catastrophic and Interrelated Complications of Diabetes Clin. J. Am. Soc. Nephrol., March 1, 2006; 1(2): 193 - 208. [Abstract] [Full Text] [PDF]

				A. M. Calafiore, M. Di Mauro, G. Di Giammarco, G. Teodori, A. L. Iaco, V. Mazzei, G. Vitolla, and M. Contini Single Versus Bilateral Internal Mammary Artery for Isolated First Myocardial Revascularization in Multivessel Disease: Long-Term Clinical Results in Medically Treated Diabetic Patients Ann. Thorac. Surg., September 1, 2005; 80(3): 888 - 895. [Abstract] [Full Text] [PDF]

				V. A. Fonseca, J. Diez, and D. B. McNamara Decreasing Restenosis Following Angioplasty: The potential of peroxisome proliferator-activated receptor {gamma} agonists Diabetes Care, November 1, 2004; 27(11): 2764 - 2766. [Full Text] [PDF]

				B. J. Leavitt, L. Sheppard, C. Maloney, R. A. Clough, J. H. Braxton, D. C. Charlesworth, R. M. Weintraub, F. Hernandez, E. M. Olmstead, W. C. Nugent, et al. Effect of Diabetes and Associated Conditions on Long-Term Survival After Coronary Artery Bypass Graft Surgery Circulation, September 14, 2004; 110(11_suppl_1): II-41 - II-44. [Abstract] [Full Text] [PDF]

				C. Locker, R. Mohr, O. Lev-Ran, G. Uretzky, A. Frimerman, Y. Shaham, and I. Shapira Comparison of bilateral thoracic artery grafting with percutaneous coronary interventions in diabetic patients Ann. Thorac. Surg., August 1, 2004; 78(2): 471 - 475. [Abstract] [Full Text] [PDF]

				J. K. Snell-Bergeon, J. E. Hokanson, L. Jensen, T. MacKenzie, G. Kinney, D. Dabelea, R. H. Eckel, J. Ehrlich, S. Garg, and M. Rewers Progression of Coronary Artery Calcification in Type 1 Diabetes: The importance of glycemic control Diabetes Care, October 1, 2003; 26(10): 2923 - 2928. [Abstract] [Full Text] [PDF]

				M. Endo, Y. Tomizawa, and H. Nishida Bilateral Versus Unilateral Internal Mammary Revascularization in Patients With Diabetes Circulation, September 16, 2003; 108(11): 1343 - 1349. [Abstract] [Full Text] [PDF]

				A. Roguin, W. Koch, A. Kastrati, D. Aronson, A. Schomig, and A. P. Levy Haptoglobin Genotype Is Predictive of Major Adverse Cardiac Events in the 1-Year Period After Percutaneous Transluminal Coronary Angioplasty in Individuals With Diabetes Diabetes Care, September 1, 2003; 26(9): 2628 - 2631. [Abstract] [Full Text] [PDF]

				K.-H. Mak and D. P. Faxon Clinical studies on coronary revascularization in patients with type 2 diabetes Eur. Heart J., June 2, 2003; 24(12): 1087 - 1103. [Abstract] [Full Text] [PDF]

				W. S. Weintraub, S. D. Clements Jr, L. V.-T. Crisco, R. A. Guyton, J. M. Craver, E. L. Jones, and C. R. Hatcher Jr Twenty-Year Survival After Coronary Artery Surgery: An Institutional Perspective From Emory University Circulation, March 11, 2003; 107(9): 1271 - 1277. [Abstract] [Full Text] [PDF]

				A. M. Calafiore, M. Di Mauro, G. Di Giammarco, M. Contini, G. Vitolla, A. Lorena Iaco, C. Canosa, and S. D'Alessandro Effect of diabetes on early and late survival after isolated first coronary bypass surgery in multivessel disease J. Thorac. Cardiovasc. Surg., January 1, 2003; 125(1): 144 - 154. [Abstract] [Full Text] [PDF]

				J. H. Cole, E. L. Jones, J. M. Craver, R. A. Guyton, D. C. Morris, J. S. Douglas Jr, Z. Ghazzal, and W. S. Weintraub Outcomes of repeat revascularization in diabetic patients with prior coronary surgery J. Am. Coll. Cardiol., December 4, 2002; 40(11): 1968 - 1975. [Abstract] [Full Text] [PDF]

				E. Van Belle, M. Perie, D. Braune, A. Chmait, T. Meurice, K. Abolmaali, E. P. McFadden, C. Bauters, J.-M. Lablanche, and M. E. Bertrand effects of coronary stenting on vessel patency and long-term clinical outcome after percutaneous coronary revascularization in diabetic patients J. Am. Coll. Cardiol., August 7, 2002; 40(3): 410 - 417. [Abstract] [Full Text] [PDF]

				T. Ono, J. Kobayashi, Y. Sasako, K. o Bando, O. Tagusari, K. Niwaya, H. Imanaka, T. Nakatani, and S. Kitamura The impact of diabetic retinopathy on long-term outcome following coronary artery bypass graft surgery J. Am. Coll. Cardiol., August 7, 2002; 40(3): 428 - 436. [Abstract] [Full Text] [PDF]

				R.T van Domburg, D.P Foley, A Breeman, L.A van Herwerden, and P.W Serruys Coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. Twenty-year clinical outcome Eur. Heart J., April 1, 2002; 23(7): 543 - 549. [Abstract] [Full Text] [PDF]

				C. Di Mario Vulnerable plaques: let's stop sinking on submerged icebergs? Eur. Heart J., March 1, 2002; 23(5): 349 - 351. [Full Text] [PDF]

				A. M. Calafiore, M. Di Mauro, M. Contini, G. Di Giammarco, M. Pano, G. Vitolla, A. Bivona, R. Carella, and S. D'Alessandro Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome Ann. Thorac. Surg., August 1, 2001; 72(2): 456 - 462. [Abstract] [Full Text] [PDF]

				C. Indolfi, D. Torella, L. Cavuto, A. M. Davalli, C. Coppola, G. Esposito, M. V. Carriero, A. Rapacciuolo, E. Di Lorenzo, E. Stabile, et al. Effects of Balloon Injury on Neointimal Hyperplasia in Streptozotocin-Induced Diabetes and in Hyperinsulinemic Nondiabetic Pancreatic Islet-Transplanted Rats Circulation, June 19, 2001; 103(24): 2980 - 2986. [Abstract] [Full Text] [PDF]

				S. C. Smith Jr, J. T. Dove, A. K. Jacobs, J. Ward Kennedy, D. Kereiakes, M. J. Kern, R. E. Kuntz, J. J. Popma, H. V. Schaff, D. O. Williams, et al. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines): A report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines (Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions J. Am. Coll. Cardiol., June 15, 2001; 37(8): 2239 - 2239. [Full Text] [PDF]

				M. Matsa, Y. Paz, J. Gurevitch, I. Shapira, A. Kramer, D. Pevny, and R. Mohr Bilateral skeletonized internal thoracic artery grafts in patients with diabetes mellitus J. Thorac. Cardiovasc. Surg., April 1, 2001; 121(4): 668 - 674. [Abstract] [Full Text] [PDF]

				N. W. Niles, P. D. McGrath, D. Malenka, H. Quinton, D. Wennberg, S. J. Shubrooks, J. F. Tryzelaar, R. Clough, M. J. Hearne, F. Hernandez Jr, et al. Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study J. Am. Coll. Cardiol., March 15, 2001; 37(4): 1008 - 1015. [Abstract] [Full Text] [PDF]

				E. Van Belle, R. Ketelers, C. Bauters, M. Perie, K. Abolmaali, F. Richard, J.-M. Lablanche, E. P. McFadden, and M. E. Bertrand Patency of Percutaneous Transluminal Coronary Angioplasty Sites at 6-Month Angiographic Follow-Up : A Key Determinant of Survival in Diabetics After Coronary Balloon Angioplasty Circulation, March 6, 2001; 103(9): 1218 - 1224. [Abstract] [Full Text] [PDF]

				D.K McGuire, H Emanuelsson, C.B Granger, E Magnus Ohman, D.J Moliterno, H.D White, D Ardissino, J.W Box, R.M Califf, and E.J Topol Influence of diabetes mellitus on clinical outcomes across the spectrum of acute coronary syndromes. Findings from the GUSTO-IIb Study Eur. Heart J., November 1, 2000; 21(21): 1750 - 1758. [Abstract] [PDF]

				E. Braunwald, E. M. Antman, J. W. Beasley, R. M. Califf, M. D. Cheitlin, J. S. Hochman, R. H. Jones, D. Kereiakes, J. Kupersmith, T. N. Levin, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina) J. Am. Coll. Cardiol., September 1, 2000; 36(3): 970 - 1062. [Full Text] [PDF]

				T. Hammoud, J.-F. Tanguay, and M. G. Bourassa Management of coronary artery disease: therapeutic options in patients with diabetes J. Am. Coll. Cardiol., August 1, 2000; 36(2): 355 - 365. [Abstract] [Full Text] [PDF]

				S. B. King III Acute myocardial infarction: are diabetics different? J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1513 - 1515. [Full Text] [PDF]

				J. Schofer, M. Schluter, T. Rau, F. Hammer, N. Haag, and D. G. Mathey Influence of treatment modality on angiographic outcome after coronary stenting in diabetic patients: a controlled study J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1554 - 1559. [Abstract] [Full Text] [PDF]

				The BARI Investigators Seven-year outcome in the Bypass Angioplasty Revascularization Investigation (BARI) by treatment and diabetic status J. Am. Coll. Cardiol., April 1, 2000; 35(5): 1122 - 1129. [Abstract] [Full Text] [PDF]

				S. B. King III and E. Mahmud Will Blocking the Platelet Save the Diabetic? Circulation, December 21, 1999; 100(25): 2466 - 2468. [Full Text] [PDF]

				S. P. Marso, A. M. Lincoff, S. G. Ellis, D. L. Bhatt, J.-F. Tanguay, N. S. Kleiman, T. Hammoud, J. E. Booth, S. K. Sapp, and E. J. Topol Optimizing the Percutaneous Interventional Outcomes for Patients With Diabetes Mellitus : Results of the EPISTENT (Evaluation of Platelet IIb/IIIa Inhibitor for Stenting Trial) Diabetic Substudy Circulation, December 21, 1999; 100(25): 2477 - 2484. [Abstract] [Full Text] [PDF]

				K. A. Eagle, R. A. Guyton, R. Davidoff, G. A. Ewy, J. Fonger, T. J. Gardner, J. P. Gott, H. C. Herrmann, R. A. Marlow, W. C. Nugent, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/ American Heart Association task force on Practice Guidelines (Committee to revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery) J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1262 - 1347. [Full Text] [PDF]

				E. Van Belle, K. Abolmaali, C. Bauters, E. P. McFadden, J.-M. Lablanche, and M. E. Bertrand Restenosis, late vessel occlusion and left ventricular function six months after balloon angioplasty in diabetic patients J. Am. Coll. Cardiol., August 1, 1999; 34(2): 476 - 485. [Abstract] [Full Text] [PDF]

				J. Gurevitch, Y. Paz, I. Shapira, M. Matsa, A. Kramer, D. Pevni, O. Lev-Ran, Y. Moshkovitz, and R. Mohr Routine use of bilateral skeletonized internal mammary arteries for myocardial revascularization Ann. Thorac. Surg., August 1, 1999; 68(2): 406 - 411. [Abstract] [Full Text] [PDF]

				C. E. Chambers, S. T Riebel, and M. Kozak Interventional Cardiology: Advances in Percutaneous Techniques for the Treatment of Cardiac Disease Seminars in Cardiothoracic and Vascular Anesthesia, July 1, 1999; 3(2): 109 - 125. [Abstract] [PDF]

				R. E. Kuntz Importance of Considering Atherosclerosis Progression When Choosing a Coronary Revascularization Strategy : The Diabetes–Percutaneous Transluminal Coronary Angioplasty Dilemma Circulation, February 23, 1999; 99(7): 847 - 851. [Full Text] [PDF]

				K. M. Detre, P. Guo, R. Holubkov, R. M. Califf, G. Sopko, R. Bach, M. M. Brooks, M. G. Bourassa, R. J. Shemin, A. D. Rosen, et al. Coronary Revascularization in Diabetic Patients : A Comparison of the Randomized and Observational Components of the Bypass Angioplasty Revascularization Investigation (BARI) Circulation, February 9, 1999; 99(5): 633 - 640. [Abstract] [Full Text] [PDF]

				S. Elezi, A. Kastrati, J.u. Pache, A. Wehinger, M. Hadamitzky, J. Dirschinger, F.-J. Neumann, and A. Schomig Diabetes mellitus and the clinical and angiographic outcome after coronary stent placement J. Am. Coll. Cardiol., December 1, 1998; 32(7): 1866 - 1873. [Abstract] [Full Text] [PDF]

				M. Sousa Uva, E. Braunberger, M. Fisher, Y. Fromes, P. H. Deleuze, J. A. Celestin, and O. M. Bical Does bilateral internal thoracic artery grafting increase surgical risk in diabetic patients? Ann. Thorac. Surg., December 1, 1998; 66(6): 2051 - 2055. [Abstract] [Full Text] [PDF]

				A. Abizaid, R. Kornowski, G. S. Mintz, M. K. Hong, A. S. Abizaid, R. Mehran, A. D. Pichard, K. M. Kent, L. F. Satler, H. Wu, et al. The influence of diabetes mellitus on acute and late clinical outcomes following coronary stent implantation J. Am. Coll. Cardiol., September 1, 1998; 32(3): 584 - 589. [Abstract] [Full Text] [PDF]

				K. E. Kip, E. L. Alderman, M. G. Bourassa, M. M. Brooks, L. Schwartz, D. R. Holmes Jr, R. M. Califf, P. L. Whitlow, B. R. Chaitman, and K. M. Detre Differential Influence of Diabetes Mellitus on Increased Jeopardized Myocardium After Initial Angioplasty or Bypass Surgery: Bypass Angioplasty Revascularization Investigation Circulation, April 23, 2002; 105(16): 1914 - 1920. [Abstract] [Full Text] [PDF]