October 17th, 2013

New Insights Into Surgery vs. Stents for Diabetics with Multivessel Disease

Last year the large NHLBI FREEDOM trial demonstrated that coronary-artery bypass graft (CABG) surgery was superior to PCI when treating diabetic patients who have multivessel coronary disease. CABG resulted in significant reductions in death and MI, but this was offset slightly by a higher rate of stroke in the CABG group. Now, a new report from FREEDOM published in JAMA suggests that the reduction in important clinical endpoints may not translate into large differences in health status and quality of life.

The quality of life substudy shows that the CABG patients had “slightly better intermediate-term health status and quality of life” than did PCI patients, though the differences between the two groups were not large. As might be expected, in the first month after the procedure PCI patients had a greater improvement in health status and quality of life. By six months, this trend reversed and CABG patients did better with less angina, greater physical activity, and a higher overall quality of life.

However, the investigators characterized these differences as small and perhaps not clinically meaningful. More than 70% of patients were free of angina in both groups at each follow-up point, while the absolute difference in complete angina relief ranged from 0.5% to 5.6%. They noted that the differences between the two revascularization procedures in FREEDOM was smaller than the difference between PCI plus optimal medical therapy versus optimal medical therapy alone in the COURAGE trial.

At 2 years there were no longer any consistent differences between the 2 groups, which the investigators attributed in part to the higher rate of repeat procedures in the PCI group.

The authors stated that their findings “suggest that CABG should be strongly preferred as the initial revascularization strategy for such patients.” But, they continue:

“Given the increased rate of stroke, as well as the well-recognized longer recovery period with CABG surgery, however, some patients who do not wish to face these acute risks may still choose the less invasive PCI strategy. For such patients, our study provides reassurance that there are not major differences in long-term health status and quality of life between the 2 treatment strategies. Nonetheless, it is important for patients to recognize that the similar late quality-of-life outcomes with PCI and CABG in the FREEDOM trial were achieved with higher rates of antianginal medication use and the need for more frequent repeat revascularization procedures among the PCI group.”

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