(Circulation. 1999;99:633-640.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Coronary Revascularization in Diabetic Patients
A Comparison of the Randomized and Observational Components of the Bypass Angioplasty Revascularization Investigation (BARI)
From the University of Pittsburgh (K.M.D, P.G., R.H., M.M.B., A.D.R.), Pittsburgh, Pa; Duke University Medical Center (R.M.C.), Durham, NC; National Heart, Lung, and Blood Institute (G.S.), Bethesda, Md; St. Louis University Sciences Center (R.B.), St. Louis, Mo; Montreal Heart Institute (M.G.B.), Montreal, Canada; Boston University Medical Center (R.J.S.), Boston, Mass; Jewish Hospital (R.J.K.), St. Louis, Mo; Mayo Clinic (R.L.F.), Rochester, NY; and Bellevue Hospital/New York University Medical Center (F.F.), New York, NY.
Correspondence to Katherine M. Detre, MD, DrPH, University of Pittsburgh, 127 Parran Hall/130 Desoto St, Pittsburgh, PA 15261. E-mail detre{at}edc.gsph.pitt.edu
Background—Patients with treated diabetes in the randomized-trial segment of the Bypass Angioplasty Revascularization Investigation (BARI) who were randomized to initial revascularization with PTCA had significantly worse 5-year survival than patients assigned to CABG. This treatment difference was not seen among diabetic patients eligible for BARI who opted to select their mode of revascularization. We hypothesized that differences in patient characteristics, assessed and unmeasured, together with the treatment selection in the registry, at least partially account for this discrepancy.
Methods and Results—Among diabetics taking insulin or oral hypoglycemic drugs at entry, angiographic and clinical presentations were comparable between randomized and registry patients. However, more registry patients were white, and registry diabetics tended to be more educated and more physically active and to report better quality of life. Procedural characteristics and in-hospital complications were comparable. The 5-year all-cause mortality rate was 34.5% in randomized diabetic patients assigned to PTCA versus 19.4% in CABG patients (P=0.0024; relative risk [RR]=1.87); corresponding cardiac mortality rates were 23.4% and 8.2%, respectively (P=0.0002; RR=3.10). The CABG benefit was more apparent among patients requiring insulin. In the registry, all-cause mortality was 14.4% for PTCA versus 14.9% for CABG (P=0.86, RR=1.10), with corresponding cardiac mortality rates of 7.5% and 6.0%, respectively (P=0.73; RR=1.07). These RRs in the registry increased to 1.29 and 1.41, respectively, after adjustment for all known differences between treatment groups.
Conclusions—BARI registry results are not inconsistent with the finding in the randomized trial that initial CABG is associated with better long-term survival than PTCA in treated diabetic patients with multivessel coronary disease suitable for either surgical or catheter-based revascularization.
Key Words: diabetes mellitus • coronary disease • angioplasty • bypass • surgery
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D.K McGuire, H Emanuelsson, C.B Granger, E Magnus Ohman, D.J Moliterno, H.D White, D Ardissino, J.W Box, R.M Califf, and E.J Topol Influence of diabetes mellitus on clinical outcomes across the spectrum of acute coronary syndromes. Findings from the GUSTO-IIb Study Eur. Heart J., November 1, 2000; 21(21): 1750 - 1758. [Abstract] [PDF]
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E. Braunwald, E. M. Antman, J. W. Beasley, R. M. Califf, M. D. Cheitlin, J. S. Hochman, R. H. Jones, D. Kereiakes, J. Kupersmith, T. N. Levin, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina) J. Am. Coll. Cardiol., September 1, 2000; 36(3): 970 - 1062. [Full Text] [PDF]
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D. M. Shindler, S. T. Palmeri, T. A. Antonelli, L. A. Sleeper, J. Boland, T. P. Cocke, J. S. Hochman, and for the SHOCK Investigators Diabetes mellitus in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry J. Am. Coll. Cardiol., September 1, 2000; 36(3_Suppl_A): 1097 - 1103. [Abstract] [Full Text] [PDF]
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T. Hammoud, J.-F. Tanguay, and M. G. Bourassa Management of coronary artery disease: therapeutic options in patients with diabetes J. Am. Coll. Cardiol., August 1, 2000; 36(2): 355 - 365. [Abstract] [Full Text] [PDF]
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K. Benson and A. J. Hartz A Comparison of Observational Studies and Randomized, Controlled Trials N. Engl. J. Med., June 22, 2000; 342(25): 1878 - 1886. [Abstract] [Full Text] [PDF]
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F. Feit, M. M. Brooks, G. Sopko, N. M. Keller, A. Rosen, R. Krone, P. B. Berger, R. Shemin, M. J. Attubato, D. O. Williams, et al. Long-Term Clinical Outcome in the Bypass Angioplasty Revascularization Investigation Registry : Comparison With the Randomized Trial Circulation, June 20, 2000; 101(24): 2795 - 2802. [Abstract] [Full Text] [PDF]
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J. Z. Ayanian and E. Braunwald Thrombolytic Therapy for Patients With Myocardial Infarction Who Are Older Than 75 Years : Do the Risks Outweigh the Benefits? Circulation, May 16, 2000; 101(19): 2224 - 2226. [Full Text] [PDF]
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D. L. Bhatt, S. P. Marso, A. M. Lincoff, K. E. Wolski, S. G. Ellis, and E. J. Topol Abciximab reduces mortality in diabetics following percutaneous coronary intervention J. Am. Coll. Cardiol., March 15, 2000; 35(4): 922 - 928. [Abstract] [Full Text] [PDF]
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S. B. King III and E. Mahmud Will Blocking the Platelet Save the Diabetic? Circulation, December 21, 1999; 100(25): 2466 - 2468. [Full Text] [PDF]
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R. E. Kuntz Importance of Considering Atherosclerosis Progression When Choosing a Coronary Revascularization Strategy : The Diabetes–Percutaneous Transluminal Coronary Angioplasty Dilemma Circulation, February 23, 1999; 99(7): 847 - 851. [Full Text] [PDF]
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