ARTICLE
Seven-year outcome in the Bypass Angioplasty Revascularization Investigation (BARI) by treatment and diabetic status
The BARI Investigators*,a,b,c
a National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
b Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
c the BARI Investigative Sites, USA
Manuscript received April 22, 1999;
revised manuscript received September 22, 1999,
accepted December 17, 1999.
Reprint requests and correspondence: Dr. Katherine M. Detre, c/o BARI Coordinating Center, University of Pittsburgh, Room 127 Parran Hall/130 DeSoto Street, Pittsburgh, Pennsylvania 15261
OBJECTIVES
To compare seven-year survival in the Bypass Angioplasty Revascularization Investigation (BARI) patients randomly assigned to percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass grafting (CABG).
BACKGROUND
The primary results of BARI reported no significant difference in five-year survival between CABG and PTCA groups. However, among patients with treated diabetes mellitus, a subgroup not specified a priori, a striking difference was seen in favor of CABG.
METHODS
Symptomatic patients with multivessel disease (n = 1,829) were randomly assigned to initial treatment strategy of CABG or PTCA and followed for an average of 7.8 years. The intention-to-treat principle was used to extend the initial five-year BARI treatment comparisons.
RESULTS
Kaplan-Meier estimates of seven-year survival for the total population were 84.4% for CABG and 80.9% for PTCA (p = 0.043). This difference could be explained by the 353 patients with treated diabetes mellitus for whom estimates of seven year survival were 76.4% CABG and 55.7% PTCA (p = 0.0011). Among the remaining 1,476 patients without treated diabetes, survival was virtually identical by assigned treatment (86.4% CABG, 86.8% PTCA, p = 0.72). The PTCA group had substantially higher subsequent revascularization rates than the CABG group (59.7% vs. 13.1%, p < 0.001); however, the changes between the five- and seven-year rates were similar for the two groups.
CONCLUSIONS
At seven years, there was a statistically significant survival advantage for patients randomized to CABG compared with PTCA. Among patients with treated diabetes mellitus, the benefit of CABG over PTCA seen at five years was more pronounced at seven years; among nondiabetic patients, there was essentially no treatment difference.
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Abbreviations and Acronyms
| | BARI | = Bypass Angioplasty Revascularization Investigation | | CABG | = coronary artery bypass grafting | | CAD | = coronary artery disease | | CCS | = Canadian Cardiovascular Society | | IMA | = internal mammary artery | | LAD | = left anterior descending coronary artery | | MI | = myocardial infarction | | NHLBI | = National Heart, Lung and Blood Institute | | PTCA | = percutaneous transluminal coronary angioplasty | | QMI | = Q wave myocardial infarction | | SVG | = saphenous vein graft |
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August 1, 2004;
27(8):
1954 - 1961.
[Abstract]
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A. Lichtenberg, U. Klima, H. Paeschke, M. Pichlmaier, S. Ringes-Lichtenberg, T. Walles, H. Goerler, and A. Haverich
Impact of diabetes on outcome following isolated minimally invasive bypass grafting of the left anterior descending artery
Ann. Thorac. Surg.,
July 1, 2004;
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[Abstract]
[Full Text]
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C. A. Herzog, J. Z. Ma, and A. J. Collins
Long-Term Outcome of Renal Transplant Recipients in the United States After Coronary Revascularization Procedures
Circulation,
June 15, 2004;
109(23):
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[Abstract]
[Full Text]
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O. Lev-Ran, R. Braunstein, N. Nesher, Y. Ben-Gal, G. Bolotin, and G. Uretzky
Bilateral versus single internal thoracic artery grafting in oral-treated diabetic subsets: comparative seven-year outcome analysis
Ann. Thorac. Surg.,
June 1, 2004;
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[Abstract]
[Full Text]
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B. D. Powell, C. S. Rihal, M. R. Bell, K. J. Zehr, and D. R. Holmes Jr
Anticipated Impact of Drug-Eluting Stents on Referral Patterns for Coronary Artery Bypass Graft Surgery: A Population-Based Angiographic Analysis
Mayo Clin. Proc.,
June 1, 2004;
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[Abstract]
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S. J. Brener, B. W. Lytle, I. P. Casserly, J. P. Schneider, E. J. Topol, and M. S. Lauer
Propensity Analysis of Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease and High-Risk Features
Circulation,
May 18, 2004;
109(19):
2290 - 2295.
[Abstract]
[Full Text]
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T. Ramanathan, S. Morita, Y. Huang, K. Shirota, T. Nishimura, X. Zheng, and S. N. Hunyor
Glucose-insulin-potassium solution improves left ventricular energetics in chronic ovine diabetes
Ann. Thorac. Surg.,
April 1, 2004;
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[Abstract]
[Full Text]
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O. Lev-Ran, R. Mohr, D. Pevni, N. Nesher, Y. Weissman, D. Loberman, and G. Uretzky
Bilateral internal thoracic artery grafting in diabetic patients: Short-term and long-term results of a 515-patient series
J. Thorac. Cardiovasc. Surg.,
April 1, 2004;
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[Abstract]
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V. M.G. Legrand, P. W. Serruys, F. Unger, B. A. van Hout, M. C.M. Vrolix, G. M.P. Fransen, T. T. Nielsen, P. K. Paulsen, R. S. Gomes, J. M.G. de Queiroz e Melo, et al.
Three-Year Outcome After Coronary Stenting Versus Bypass Surgery for the Treatment of Multivessel Disease
Circulation,
March 9, 2004;
109(9):
1114 - 1120.
[Abstract]
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C Casey and D. P Faxon
Multi-vessel coronary disease and percutaneous coronary intervention
Heart,
March 1, 2004;
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341 - 346.
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N. E.J. West, P. N. Ruygrok, C. M.C. Disco, M. W.I. Webster, W. K. Lindeboom, W. W. O'Neill, N. F. Mercado, and P. W. Serruys
Clinical and Angiographic Predictors of Restenosis After Stent Deployment in Diabetic Patients
Circulation,
February 24, 2004;
109(7):
867 - 873.
[Abstract]
[Full Text]
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D. R. Holmes Jr, B. G. Firth, and D. L. Wood
Paradigm shifts in cardiovascular medicine
J. Am. Coll. Cardiol.,
February 18, 2004;
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[Abstract]
[Full Text]
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C. S. Rihal, D. L. Raco, B. J. Gersh, and S. Yusuf
Indications for Coronary Artery Bypass Surgery and Percutaneous Coronary Intervention in Chronic Stable Angina: Review of the Evidence and Methodological Considerations
Circulation,
November 18, 2003;
108(20):
2439 - 2445.
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R. A. Henderson, S. J. Pocock, T. C. Clayton, R. Knight, K. A. A. Fox, D. G. Julian, D. A. Chamberlain, and Second Randomized Intervention Treatment of Angina
Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy
J. Am. Coll. Cardiol.,
October 1, 2003;
42(7):
1161 - 1170.
[Abstract]
[Full Text]
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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]
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C. Torp-Pedersen, C. Rask-Madsen, I. Gustafsson, F. Gustafsson, and L. Kober
Diabetes mellitus and cardiovascular risk: just another risk factor?
Eur. Heart J. Suppl.,
August 1, 2003;
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[Abstract]
[PDF]
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K.-H. Mak and D. P. Faxon
Clinical studies on coronary revascularization in patients with type 2 diabetes
Eur. Heart J.,
June 2, 2003;
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[Abstract]
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S. N. Hoffman, J. A. TenBrook Jr, M. P. Wolf, S. G. Pauker, D. N. Salem, and J. B. Wong
A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes
J. Am. Coll. Cardiol.,
April 16, 2003;
41(8):
1293 - 1304.
[Abstract]
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D. K. McGuire, K. J. Anstrom, and E. D. Peterson
Influence of the Bypass Angioplasty Revascularization Investigation National Heart, Lung, and Blood Institute Diabetic Clinical Alert on Practice Patterns: Results from the National Cardiovascular Network Database
Circulation,
April 15, 2003;
107(14):
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[Abstract]
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A Rodriguez, M Rodriguez Alemparte, J Baldi, J Navia, A Delacasa, D Vogel, R Oliveri, C Fernandez Pereira, V Bernardi, W O'Neill, et al.
Coronary stenting versus coronary bypass surgery in patients with multiple vessel disease and significant proximal LAD stenosis: results from the ERACI II study
Heart,
February 1, 2003;
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184 - 188.
[Abstract]
[Full Text]
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T. M. Sundt III, B. J. Gersh, and H. C. Smith
Indications for Coronary Revascularization
Card. Surg. Adult,
January 1, 2003;
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L. Schwartz, K. E. Kip, R. L. Frye, E. L. Alderman, H. V. Schaff, and K. M. Detre
Coronary Bypass Graft Patency in Patients With Diabetes in the Bypass Angioplasty Revascularization Investigation (BARI)
Circulation,
November 19, 2002;
106(21):
2652 - 2658.
[Abstract]
[Full Text]
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S. P. Sedlis, D. A. Morrison, J. D. Lorin, R. Esposito, G. Sethi, J. Sacks, W. Henderson, F. Grover, K. B. Ramanathan, D. Weiman, et al.
Percutaneous coronary intervention versus coronary bypass graft surgery for diabetic patients with unstable angina and risk factors for adverse outcomes with bypass: outcome of diabetic patients in the AWESOME randomized trial and registry
J. Am. Coll. Cardiol.,
November 6, 2002;
40(9):
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[Abstract]
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C. A. Herzog, J. Z. Ma, and A. J. Collins
Comparative Survival of Dialysis Patients in the United States After Coronary Angioplasty, Coronary Artery Stenting, and Coronary Artery Bypass Surgery and Impact of Diabetes
Circulation,
October 22, 2002;
106(17):
2207 - 2211.
[Abstract]
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I. Malik and A. Berger
Science commentary: Coronary angioplasty and stenting
BMJ,
September 7, 2002;
325(7363):
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T. Y. Goraya, C. L. Leibson, P. J. Palumbo, S. A. Weston, J. M. Killian, E. A. Pfeifer, S. J. Jacobsen, R. L. Frye, and V.e. L. Roger
Coronary atherosclerosis in diabetes mellitus: A population-based autopsy study
J. Am. Coll. Cardiol.,
September 4, 2002;
40(5):
946 - 953.
[Abstract]
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V. Mathew, S.H. Wilson, G.W. Barsness, R.L. Frye, R. Lennon, and D.R. Holmes
Comparative outcomes of percutaneous coronary interventions in diabetics vs non-diabetics with prior coronary artery bypass grafting
Eur. Heart J.,
September 2, 2002;
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[Abstract]
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P F Ludman
Percutaneous coronary intervention in diabetics: time to consider "intimal remodelling therapy"?
Heart,
September 1, 2002;
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R. M. Califf and D. L. DeMets
Principles From Clinical Trials Relevant to Clinical Practice: Part II
Circulation,
August 27, 2002;
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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;
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[Abstract]
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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;
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428 - 436.
[Abstract]
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W. Cheng, T. A. Denton, G. P. Fontana, S. Raissi, C. Blanche, R. M. Kass, K. E. Magliato, J. Mirocha, and A. Trento
Off-pump coronary surgery: Effect on early mortality and stroke
J. Thorac. Cardiovasc. Surg.,
August 1, 2002;
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[Abstract]
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D. B. Mark and M. A. Hlatky
Medical Economics and the Assessment of Value in Cardiovascular Medicine: Part II
Circulation,
July 30, 2002;
106(5):
626 - 630.
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M. Roffi, D. J. Moliterno, B. Meier, E. R. Powers, C. L. Grines, P. M. DiBattiste, H. C. Herrmann, M. Bertrand, K. E. Harris, L. A. Demopoulos, et al.
Impact of Different Platelet Glycoprotein IIb/IIIa Receptor Inhibitors Among Diabetic Patients Undergoing Percutaneous Coronary Intervention: Do Tirofiban and ReoPro Give Similar Efficacy Outcomes Trial (TARGET) 1-Year Follow-Up
Circulation,
June 11, 2002;
105(23):
2730 - 2736.
[Abstract]
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P.J. de Feyter, P.W. Serruys, F. Unger, R. Beyar, V. de Valk, S. Milo, R. Simon, D. Regensburger, P.A. Crean, E. McGovern, et al.
Bypass Surgery Versus Stenting for the Treatment of Multivessel Disease in Patients With Unstable Angina Compared With Stable Angina
Circulation,
May 21, 2002;
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A Kapur and I S Malik
Is surgery still the preferred option for coronary revascularisation in diabetics with multivessel coronary disease?
Heart,
May 1, 2002;
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F.R. Eberli and B. Meier
Coronary bypass surgery vs coronary angioplasty: a look to the past for new insights into the future
Eur. Heart J.,
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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.,
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T. J. Vander Salm, K. E. Kip, R. H. Jones, H. V. Schaff, R. J. Shemin, G. S. Aldea, and K. M. Detre
What constitutes optimal surgical revascularization?: Answers from the bypass angioplasty revascularization investigation (BARI)
J. Am. Coll. Cardiol.,
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P. B. Berger, J. L. Velianou, H. Aslanidou Vlachos, F. Feit, A. K. Jacobs, D. P. Faxon, M. Attubato, N. Keller, M. L. Stadius, B. H. Weiner, et al.
Survival following coronary angioplasty versus coronary artery bypass surgery in anatomic subsets in which coronary artery bypass surgery improves survival compared with medical therapy: Results from the Bypass Angioplasty Revascularization Investigation (BARI)
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S. D. Fihn, S. V. Williams, J. Daley, and R. J. Gibbons
Guidelines for the Management of Patients with Chronic Stable Angina: Treatment
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