Trends in Guideline-Driven Revascularization in Diabetic Patients with Multivessel Coronary Heart Disease

Abstract

In diabetes patients with chronic ≥3 vessel disease, coronary artery bypass grafting (CABG) holds a class I recommendation in the American College of Cardiology and American Heart Association (ACC/AHA) 2011 guidelines, and this classification has not changed to date. Much of the literature has focused upon whether CABG or percutaneous coronary intervention (PCI) produces better outcomes; there is a paucity of data comparing the odds of receiving these procedures. A secondary analysis was conducted in a de-identified database comprised of 30,482 patients satisfying the entry criteria. Odds of occurrence (CABG, PCI) were determined as the binary dependent variable in period 1, (17 October 2009 through 31 December 2011), and period 2 (1 January 2013 through 16 March 2015), before and after the 2011 guidelines, while controlling for gender, ethnicity/race, and ischemic heart disease as covariates. The odds of performing CABG rather than PCI in period 2 were not statistically significantly different than in period 1 (p = 0.400). The logistic regression model chi-square statistic was statistically significant, with χ2 (7) = 308.850, p < 0.0001. The Wald statistic showed that ethnicity/race (African American, Caucasian, Hispanic and Other), gender, and heart disease contributed significantly to the prediction model with p < 0.05, but ethnicity ‘Unknown’ did not. The odds of CABG versus PCI in period 2 were 0.98 times those in period 1 95% confidence interval (CI) = (0.925, 1.032), statistically controlling for covariates. There was no significant rise in the odds of undergoing a CABG among this dataset of high-risk patients with diabetes and multivessel coronary heart disease. Modern practice has evolved regarding patient choice and additional variables that impact the final revascularization method employed. The degree to which odds of occurrence of procedures are a reliable surrogate for provider compliance with guidelines remains uncertain.

Temporal Trend in Revascularization for Patients With Ischemic Cardiomyopathy and Multivessel Coronary Artery Disease

“…It is important to highlight that there has been a nationwide decrease in the volume of revascularization procedures. 17 , 18 , 19 , 20 , 21 , 22 , 25 Our data are consistent with these results; for instance, the stabilization in the trend of CABG procedures in later years was also observed in a previously published national study but slightly earlier, starting from 2009. 20 , 26 This change in trend occurred around the time the STICH trial results were published, demonstrating the role of CABG in reducing death from cardiovascular causes and death from any cause or cardiovascular‐related hospitalization.…”

“…However, it is different from the trend seen in the general diabetic population undergoing revascularization, where the odds of undergoing CABG are the same as those for undergoing PCI. 25 , 28 …”

“…In addition, we conducted a segmented regression known as joinpoint regression analysis to evaluate trends over time. 25 , 26 This statistical method identifies years in which a significant change in the linear slope of the trend occurred (a joinpoint). For model specifications, we used Poisson variance and grid methods.…”

Screening for Glucose Metabolism Disorders, Assessment the Disse Insulin Resistance Index and Hospital Prognosis of Coronary Artery Bypass Surgery

“…However, some data could not support these statements, in particular, Djupsjo C. et al did not reveal an effect of newly diagnosed diabetes and previously known pre-diabetes on the long-term survival in patients who underwent CABG [ 11 ]. Additionally, not all studies noted an increase in the number of CABGs performed in multivessel coronary artery disease in diabetes mellitus [ 12 ]. Therefore, the search for optimal treatment tactics in this category of patients continues [ 13 , 14 , 15 ].…”

Translating Scientific Evidence Into Clinical Practice: Closing the Loop

“…vital, tracking the whole cycle and understating the possible challenges to implement evidence into practice is not always performed. 7,8 In this issue of the Canadian Journal of Cardiology, Miller and colleagues compared patterns of practice regarding coronary revascularization in patients with diabetes and multivessel disease in British Columbia (BC) before and after the publication of the FREEDOM trial, using a population-based registry. 9 The ratio of PCI:CABG procedures in this population was 1.59 (95% CI, 1.48-1.70) before FREEDOM and declined to 0.88 (95% CI, 0.75-1.01) after the publication of the trial (P < 0.01).…”