Coronary Artery Bypass Grafting is Superior to Percutaneous Coronary Intervention in Diabetics with Coronary Artery Disease

A dramatic increase in percutaneous coronary intervention (PCI), coupled with a similar decrease in coronary artery bypass grafting (CABG) has characterized the treatment of coronary artery disease for the 20 years.

The just released FREEDOM trial results[1] have once again confirmed that diabetic patients with coronary artery disease have better outcomes with CABG than with PCI – even if contemporaneous techniques are used.

Significant this time is the superiority of CABG for all risk factors examined, not just in patients with depressed LV function and 3-vessel CAD, but even more significantly, in patients even with a low SYNTAX score and also 2-vessel CAD:

This should not be a surprise; since the mid-nineties many previous studies, including one that I co-authored in 2001.[2], have demonstrated the same. After publication of the original BARI trial [3] in 1997 the National Heart, Lung, and Blood Institute (NHLBI) issued a clinical alert [4] that CABG had better rates of survival than PCI in patients with diabetes.

The NHLBI recommendations have been largely ignored by cardiologists ever since, as have the results of at least 10 other studies that confirmed the original BARI results.

In an editorial that accompanied the article, the author discussed two possible explanations for the increasing numbers of diabetics treated with PCI despite evidence to the contrary:

• Earlier studies were ignored because of outdated techniques;
• The same physician who does the diagnostic coronary angiography, recommends the treatment, and performs the PCI immediately. An informed discussion about alternative treatment options, either medical therapy or CABG does not take place.

What was not discussed is this:

• The increase in PCI in this high-risk sub group suggests a specific practice of “target lesion” revascularization rather than an emphasis on complete revascularization, not influenced by across the board recommendations from the various medical associations;
• It also suggests long term considerations play little or no role and that device manufacturers and economic benefit may have a much larger influence on treatment for CAD than simply doing what is best for the patient;
• “Percutaneous coronary intervention (stenting)… cost(s) billions of dollars and (has supported) the existence of (an) entire specialty for many years.” [5]