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J Am Coll Cardiol, 2001; 37:1008-1015 © 2001 by the American College of Cardiology Foundation |
* Department of Medicine and Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
Section of Cardiology, Maine Medical Center, Portland, Maine, USA
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.
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