FREEDOM & the good life: CABG, PCI provide long-term improvement

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Patients with diabetes and multivessel coronary artery disease (CAD) experience no long-term differences in quality of life whether they undergo PCI or CABG, a FREEDOM trial substudy found. The results were published in the Oct. 16 issue of the JAMA.

The randomized clinical trial FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease) showed that CABG in patients with diabetes and multivessel CAD offered mortality and MI benefits compared with PCI using drug-eluting stents but it also carried a higher stroke risk. In this substudy, Mouin S. Abdallah, MD, MSc, of Saint Luke’s Mid America Heart institute in Kansas City, Mo., and colleagues assessed outcomes from the patient’s perspective.

They looked at symptoms, functional status and quality of life in the 1,880 patients who had answered the Seattle Angina Questionnaire (SAQ) as part of FREEDOM. The patients were enrolled between 2005 and 2010, with questionnaires given at baseline prior to randomization, at one, six and 12 months after randomization and then annually. They focused on three SAQ domains: angina frequency, physical limitations and quality of life.  

The two treatment groups were well matched at baseline. Their response rate was 80 percent during the first three years of follow-up and 70 percent in the next two years.

For angina frequency, CABG received slightly higher (better) scores at one-year and two-year follow-up but by the third-year follow-up CABG and PCI scores were similar.

Both CABG and PCI showed substantial improvement in physical limitation and quality of life, with PCI taking the lead at one month. At six months, PCI still held a slight edge for physical limitations but the two treatments were similar for quality of life. At one-year through three-year follow-up, CABG showed higher scores for both domains. After three years, there was no difference in either domain.

Abdallah et al summarized that both PCI and CABG provided “substantial and durable improvements in cardiovascular-specific health status.” CABG, in which patients face a recovery period from surgery, had a slower improvement in health status in the short term.  

They noted that the introduction of drug-eluting stents led to a reduction in the need for revascularization compared to the era of bare-metal stents and balloon angioplasty. Nonetheless, in FREEDOM the rate of revascularization was twice as high in the PCI group compared with the CABG group.

“It is possible that the higher rates of repeat revascularization seen after PCI in FREEDOM mitigated any differences in angina frequency and quality of life between the two strategies,” they wrote. “Whether further improvements in DES [drug-eluting stents] technology would eliminate any health status benefit of CABG over PCI in the diabetic population is unknown.”

Angina relief was better with CABG, especially among patients with daily or weekly angina at baseline.  “These findings suggest CABG should be strongly preferred as the initial revascularization strategy for such patients,” they advised.

Patients concerned about stroke might prefer PCI, which offers long-term health status and quality of life equivalent to CABG. But they cautioned that in FREEDOM the PCI group also needed more frequent revascularization and had higher rates of use of medications to treat angina.

For more on FREEDOM, please read “ FREEDOM sets us free—for the sickest patients” in Cardiovascular Business.