Abstract 18327: Angiographic Criteria Determine Effectiveness of CABG among Patients with Diabetes and Stable Ischemic Heart Disease: Results from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial
Background: The BARI 2D trial demonstrated that among patients selected for CABG, prompt revascularization lowered the composite rate of death, myocardial infarction and stroke (D/MI/S) beyond medical therapy alone. Using angiographic criteria, we sought to define patient subgroups in whom CABG reduced the risk of D/MI/S and MI.
Methods: BARI 2D randomized 2368 patients with type 2 diabetes and stable ischemic heart disease to prompt revascularization with medical therapy (REV) versus medical therapy alone (MED). Prior to study entry, the cardiologist determined whether PCI or CABG was preferred, and randomization was stratified by this selection. Event rates were compared for REV versus MED in subgroups defined by randomization strata and specified angiographic factors. We developed an angiographic risk score, based on myocardial jeopardy index (MJI), number of coronary lesions, ejection fraction, and prior revascularization, that predicted D/MI/S in the overall population; risk tertiles were created from this score.
Results: Within the stratum of patients selected for CABG (n=763), REV was associated with a lower 5-year D/MI/S rate than MED among patients with the highest MJI scores (24.2% vs 32.2% p=0.004) and a lower 5-year MI rate in patients with the highest MJI scores (10.5% vs 23.6%, p=0.001) and in those with 3 vessel disease (10.0% vs 21.8%, p=0.003). These treatment differences were not significant among patients with mid-range MJI or with 2 vessel disease (p>0.50). In the CABG stratum, REV was associated with lower D/MI/S rates and lower MI rates in the highest angiographic risk tertile (Figure, p<0.001) but not the middle risk tertile.
Conclusions: The rate of MI is reduced by CABG for high risk patients whether risk is defined as extent of CAD (3VD), myocardial jeopardy (MJI) or an angiographic risk score. In diabetic patients with mild or no angina with extensive CAD and substantial myocardium at risk, CABG should be strongly considered as initial treatment.
- © 2010 by American Heart Association, Inc.