Revascularization Trends in Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease Presenting With Non–ST Elevation Myocardial Infarction

Abstract

Background-Current guidelines recommend surgical revascularization (coronary artery bypass graft [CABG]) over percutaneous coronary intervention (PCI) in patients with diabetes mellitus and multivessel coronary artery disease. Few data are available describing revascularization patterns among these patients in the setting of non-ST-segment-elevation myocardial infarction. Methods and Results-Using Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (ACTION Registry-GWTG), we compared the in-hospital use of different revascularization strategies (PCI versus CABG versus no revascularization) in diabetes mellitus patients with non-ST-segment-elevation myocardial infarction who had angiography, demonstrating multivessel coronary artery disease between July 2008 and December 2014. Factors associated with use of CABG versus PCI were identified using logistic multivariable regression analyses. A total of 29 769 patients from 539 hospitals were included in the study, of which 10 852 (36.4%) were treated with CABG, 13 760 (46.2%) were treated with PCI, and 5157 (17.3%) were treated without revascularization. The overall use of revascularization increased over the study period with an increase in the proportion undergoing PCI (45% to 48.9%; P trend =0.0002) and no change in the proportion undergoing CABG (36.1% to 34.7%; p trend =0.88). There was significant variability between participating hospitals in the use of PCI and CABG (range: 22%-100%; 0%-78%, respectively; P value <0.0001 for both). Patient-level, but not hospital-level, characteristics were statistically associated with the use of PCI versus CABG, including anatomic severity of the disease, early treatment of adenosine diphosphate receptor antagonists at presentation, older age, female sex, and history of heart failure. Conclusions-Among patients with diabetes mellitus and multivessel coronary artery disease presenting with non-ST-segment-elevation myocardial infarction, only one third undergo CABG during the index admission. Furthermore, the use of PCI, but not CABG, increased modestly over the past 6 years. (Circ Cardiovasc Qual Outcomes. 2016;9:197-205.

Profile of Acute Coronary Syndrome In Young People: A Hospital Based Observational Study in Western Nepal

“…This study also suggested smoking as a crucial risk factor among all other risk factors in cases of 21 ACS as compared to stable CAD. Risk factors like diabetes is 24 associated with mul vessel disease and poor prognosis. In our study diabetes was seen in 14% of individuals which is 10 comparable to a study done in central Nepal.…”

Treatment of Higher-Risk Patients With an Indication for Revascularization

“…19 Thus, although revascularization may have been overused in lower-risk patients, within the overall decline in volume is the possibility of underuse of invasive testing and revascularization procedures in other subgroups of patients such as those at higher risk for adverse events. 12,[20][21][22][23][24][25] A patient population among the least likely to be offered PCI but with a clinical indication for revascularization consists of patients with CAD who also are at higher or extreme (inoperable) surgical risk. [26][27][28] Although complete revascularization through PCI is a less invasive alternative to surgical revascularization and may therefore offer advantages to patients at high risk for surgery, early experiences with PCI conducted in the balloon angioplasty and early stent eras demonstrated lower success rates and higher rates of complications with PCI in this group of patients.…”

“…23,24,[26][27][28] There are several possible reasons why this group of patients may not be offered PCI. Some patients may have comorbidities that are too extensive for a (potentially futile) revascularization procedure to make an appreciable difference in outcome.…”

Can the onset of heart failure be delayed by treating diabetic cardiomyopathy?

“…What’s more, most of patients with diabetes aren’t referred directly to surgical revascularization after being diagnosed with CAD. Pandey et al [29] draw attention to the fact that only one-third of diabetic patients admitted to hospital due to NSTEMI (non-STsegment elevation myocardial infarction) underwent surgical revascularization.…”