The prevalence of diabetes
mellitus has assumed epidemic proportion in Western countries as well as in the
rest of the world. Coronary artery disease (CAD) is quite common in adults with
diabetes mellitus and is a major cause of morbidity and mortality in them.
For patients with multivessel
coronary artery disease, revascularization procedures like coronary artery
bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) with
drug-eluting stent (DES) are commonly performed. Diabetic patients undergoing
such procedures experience worse outcomes than non-diabetic patients.
During CABG, a healthy artery or
vein from the body is connected, or grafted, to the blocked coronary artery.
The grafted artery or vein bypasses the blocked portion of the coronary artery,
thus creating a new path for oxygen-rich blood to flow to the heart muscle.
which is also known as angioplasty,
is a procedure where a deflated balloon is passed via a catheter through blood
vessels until it reaches the site of blockage. Here, the balloon is inflated to
open the artery, allowing blood to flow. A stent is usually placed at the site
of blockage to keep the artery open. Drug-eluting stents release a drug like
sirolimus or paclitaxel that prevents restenosis.
Several trials have been conducted in the past
few decades to understand as to which mode of revascularization (CABG or PCI)
is safer. One such recent trial was the FREEDOM trial (Future Revascularization
Evaluation in Patients with Diabetes Mellitus: Optimal Management of
Multivessel Disease), which was published in the New England Journal of Medicine
The main objective of the study was to evaluate whether PCI with
drug-eluting stents (PCI/DES) is more or less effective than the existing
standard of care, CABG, in patients with diabetes mellitus.
The study enrolled 1900 adults with diabetes
mellitus (Type 1 or Type 2) with angiographically confirmed multivessel CAD. The
patients' mean age was 63.1±9.1 years; 29% participants were women, and 83% had
three-vessel disease. The participants were randomly assigned to receive one of
the interventions.. The PCI group also received anti-clotting therapies.
The study found that there
was increased all-cause mortality in the PCI group (16.3% in the PCI group
versus 10.9% in the CABG group) at the end of a 5-year period. It was
also seen that 13.9%
of patients in the PCI group had a myocardial infarction, as compared with 6%
in the CABG group. However, there
were fewer strokes in the PCI group (2.4%)
than in the CABG group (5.2%)
There was also a significant difference in rates
of major adverse cardiovascular and cerebrovascular events at 1 year after the
procedure, with 16.8% in the PCI group versus 11.8% in the CABG group suffering
from these adverse events.
the results of the trial, it was concluded that CABG was superior to PCI with
drug-eluting stents in patients with diabetes and multivessel coronary artery
disease as CABG significantly reduced rates of death and myocardial infarction.
However, it was associated with a higher rate of stroke.
for Multivessel Revascularization in Patients with Diabetes; Michael Farkouh et
al; N Engl J Med 2012; 367:2375-2384