JACC: PCI favored over CABG for diabetics with multivessel disease

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The majority of diabetic patients with multivessel disease are selected for PCI rather than CABG, largely based on angiographic features related to the extent, location and nature of the coronary artery disease (CAD), as well as geographic, demographic and clinical factors, according to the BARI 2D trial in the May issue of the Journal of the American College of Cardiology: Cardiovascular Interventions.

Lauren J. Kim, PhD, from the National Institute on Aging in Bethesda, Md., and colleagues evaluated demographic, clinical and angiographic factors influencing the selection of CABG surgery versus PCI in diabetic patients with multivessel CAD between Jan. 1, 2001, and March 31, 2005 in the BARI 2D (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes) trial.

In the BARI 2D trial, the investigators reported that the selected revascularization strategy, either CABG or PCI, was based on physician discretion, declared independent of randomization to either immediate or deferred revascularization if clinically warranted. They analyzed factors favoring selection of CABG versus PCI in 1,593 diabetic patients with multivessel CAD enrolled between 2001 and 2005.

The authors reported that the selection of CABG over PCI was declared in 44 percent of patients and was driven by angiographic factors including triple vessel disease, left anterior descending stenosis (at least 70 percent), proximal left anterior descending stenosis (more than 50 percent), total occlusion and multiple class C lesions.

Nonangiographic predictors of CABG included age of at least 65 years and locations in non-U.S. regions, Kim and colleagues said. "The absence of prior PCI and the availability of drug-eluting stents (DES) conferred a lower probability of choosing," they wrote.

The authors noted that there has been "remarkably" little change in the angiographic predictors that drive a selection of CABG rather than PCI in patients with multivessel CAD, from the era when only balloon angioplasty was available, when data from the BARI registry was gathered between 1988 and 1991.

Kim and colleagues concluded that the "treatment selection varied substantially across geographic regions and across clinical sites within regions, reflecting a lack of consensus regarding optimal therapy in contemporary practice. Finally, the introduction of the first-generation DES decreased the likelihood of the selection of CABG."