Bypass Surgery or Stenting for Left Main Coronary Artery Disease in Patients With Diabetes

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

卷:73

Article

Milojevic, Milan¹  Serruys, Patrick W.²  Sabik, Joseph F., III³  Kandzari, David E.⁴  Schampaert, Erick⁵  van Boven, Ad J.⁶  Horkay, Ferenc⁷  Ungi, Imre⁸  Mansour, Samer⁹  Banning, Adrian P.¹⁰  Taggart, David P.¹⁰  Sabate, Manel¹¹  Gershlick, Anthony H.¹²  Bochenek, Andrzej¹³  Pomar, Jose¹¹  Lembo, Nicholas J.¹⁴  Noiseux, Nicolas⁹  Puskas, John D.¹⁵  Crowley, Aaron¹⁶  Kosmidou, Ioanna^14,16  Mehran, Roxana^16,17  Ben-Yehuda, Ori^14,16  Genereux, Philippe^5,16,18  Pocock, Stuart J.¹⁹  Simonton, Charles A.²⁰  Stone, Gregg W.^14,16  Kappetein, Arie Pieter¹ 

[1] Erasmus Sch Ctr, Rotterdam, Netherlands

[2] Imperial Coll Sci Technol & Med, London, England

[3] UH Cleveland Med Ctr, Cleveland, OH USA

[4] Piedmont Heart Inst, Atlanta, GA USA

[5] Hop Sacre Coeur Montreal, Montreal, PQ, Canada

[6] Med Ctr Leeuwarden, Leeuwarden, Netherlands

[7] Semmelweis Univ, Budapest, Hungary

[8] Univ Szeged, Szeged, Hungary

[9] Ctr Hosp Univ Montreal, Montreal, PQ, Canada

[10] John Radcliffe Hosp, Oxford, England

[11] Hosp Clin Barcelona, Barcelona, Spain

[12] Glenfield Hosp, Leicester, Leics, England

[13] Amer Heart Poland, Katowice, Poland

[14] Columbia Univ, Med Ctr, New York Presbyterian Hosp, New York, NY USA

[15] Mt Sinai Heart Mt Sinai St Lukes, New York, NY USA

[16] Cardiovasc Res Fdn, Clin Trials Ctr, New York, NY USA

[17] Icahn Sch Med Mt Sinai, Zena & Michael A Wiener Cardiovasc Inst, New York, NY 10029 USA

[18] Morristown Med Ctr, Gagnon Cardiovasc Inst, Morristown, NJ USA

[19] London Sch Hyg & Trop Med, London, England

[20] Abbott Vasc, Santa Clara, CA USA

关键词: coronary artery bypass grafting;    diabetes;    left main disease;    percutaneous coronary intervention;    SYNTAX score;   

DOI  :  10.1016/j.jacc.2019.01.037

来源: Elsevier

【 摘 要 】

BACKGROUND The randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial reported a similar rate of the 3-year composite primary endpoint of death, myocardial infarction (MI), or stroke in patients with left main coronary artery disease (LMCAD) and site-assessed low or intermediate SYNTAX scores treated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Whether these results are consistent in high-risk patients with diabetes, who have fared relatively better with CABG in most prior trials, is unknown. OBJECTIVES In this pre-specified subgroup analysis from the EXCEL trial, the authors sought to examine the effect of diabetes in patients with LMCAD treated with PCI versus CABG. METHODS Patients (N = 1,905) with LMCAD and site-assessed low or intermediate CAD complexity (SYNTAX scores <= 32) were randomized 1: 1 to PCI with everolimus-eluting stents versus CABG, stratified by the presence of diabetes. The primary endpoint was the rate of a composite of all-cause death, stroke, or MI at 3 years. Outcomes were examined in patients with (n = 554) and without (n = 1,350) diabetes. RESULTS The 3-year composite primary endpoint was significantly higher in diabetic compared with nondiabetic patients (20.0% vs. 12.9%; p < 0.001). The rate of the 3-year primary endpoint was similar after treatment with PCI and CABG in diabetic patients (20.7% vs. 19.3%, respectively; hazard ratio: 1.03; 95% confidence interval: 0.71 to 1.50; p = 0.87) and nondiabetic patients (12.9% vs. 12.9%, respectively; hazard ratio: 0.98; 95% confidence interval: 0.73 to 1.32; p = 0.89). All-cause death at 3 years occurred in 13.6% of PCI and 9.0% of CABG patients (p = 0.046), although no significant interaction was present between diabetes status and treatment for all-cause death (p = 0.22) or other endpoints, including the 3-year primary endpoint (p = 0.82) or the major secondary endpoints of death, MI, or stroke at 30 days (p = 0.61) or death, MI, stroke, or ischemia-driven revascularization at 3 years (p = 0.65). CONCLUSIONS In the EXCEL trial, the relative 30-day and 3-year outcomes of PCI with everolimus-eluting stents versus CABG were consistent in diabetic and nondiabetic patients with LMCAD and site-assessed low or intermediate SYNTAX scores.(Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776) (C) 2019 Published by Elsevier on behalf of the American College of Cardiology Foundation.

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