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J Am Coll Cardiol, 2001; 37:1008-1015
© 2001 by the American College of Cardiology Foundation
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CLINICAL STUDY: INTERVENTIONAL CARDIOLOGY

Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study

Nathaniel W. Niles, MD*, Paul D. McGrath, MD, FACC{dagger}, David Malenka, MD, FACC*, Hebe Quinton, MS*, David Wennberg, MD{ddagger}, Samuel J. Shubrooks, MD, FACC§, Joan F. Tryzelaar, MD{dagger}, Robert Clough, MD||, Michael J. Hearne, MD, FACC, Felix Hernandez, Jr, MD, FACC||, Matthew W. Watkins, MD, FACC#, Gerald T. O’Connor, PhD, FACC* for the Northern New England Cardiovascular Disease Study Group

* Department of Medicine and Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
{dagger} Section of Cardiology, Maine Medical Center, Portland, Maine, USA
{ddagger} Maine Medical Assessment Foundation, Augusta, Maine, USA
§ Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
|| Eastern Maine Medical Center, Bangor, Maine, USA
Catholic Medical Center, Manchester, New Hampshire, USA
# Cardiology Unit, Fletcher Allen Health Care, Burlington, Vermont, USA

Manuscript received May 1, 2000; revised manuscript received September 25, 2000, accepted December 6, 2000.

Reprint requests and correspondence: Dr. Nathaniel W. Niles, Cardiology Section, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire 03756
nat.niles{at}hitchcock.org

OBJECTIVES

We sought to assess survival among patients with diabetes and multivessel coronary artery disease (MVD) after percutaneous coronary intervention (PCI) and after coronary artery bypass grafting surgery (CABG).

BACKGROUND

The Bypass Angioplasty Revascularization Investigation (BARI) demonstrated that diabetics with MVD survive longer after initial CABG than after initial PCI. Other randomized trials or observational databases have not conclusively reproduced this result.

METHODS

A large, regional database was linked to the National Death Index to assess five-year mortality. Of 7,159 consecutive patients with diabetes who underwent coronary revascularization in northern New England during 1992 to 1996, 2,766 (38.6%) were similar to those randomized in the BARI trial. Percutaneous coronary intervention was the initial revascularization strategy in 736 patients and CABG in 2,030. Cox proportional hazards regression was used to calculate risk-adjusted hazard ratios (HR) and 95% confidence intervals (CI 95%).

RESULTS

Patients who underwent PCI were younger, had higher ejection fractions and less extensive coronary disease. After adjusting for differences in baseline clinical characteristics, patients with diabetes treated with PCI had significantly greater mortality relative to those undergoing CABG (HR = 1.49; CI 95%: 1.02 to 2.17; p = 0.037). Mortality risk tended to increase more among 1,251 patients with 3VD (HR = 2.02; CI 95%: 1.04 to 3.91; p = 0.038) than among 1,515 patients with 2VD (HR = 1.33; CI 95%: 0.84 to 2.1; p = 0.21).

CONCLUSIONS

In this analysis of a large regional contemporary database of patients with diabetes selected to be similar to those enrolled in the BARI trial, five-year mortality was significantly increased after initial PCI. This supports the BARI conclusion on initial revascularization of patients with diabetes and MVD.

Abbreviations and Acronyms
  BARI = Bypass Angioplasty Revascularization Investigation
  CABG = coronary artery bypass grafting
  CABRI = Coronary Angioplasty versus Bypass Revascularization Investigation
  CHF = congestive heart failure
  CI 95% = 95% confidence interval
  COPD = chronic obstructive pulmonary disease
  EAST = Emory Angioplasty versus Surgery Trial
  HR = hazard ratio
  MAHI = Mid America Heart Institute
  MI = myocardial infarction
  MVD = multivessel coronary artery disease
  NHLBI = National Heart, Lung and Blood Institute
  PCI = percutaneous coronary intervention
  PTCA = percutaneous transluminal coronary angioplasty
  PVD = peripheral vascular disease
  RITA = Randomized Intervention Treatment of Angina
  2VD = two-vessel coronary artery disease
  3VD = three-vessel coronary artery disease




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