On 2014 Apr 08, Dr Nicholas D Gollop commented:

Dear Jamil Hajj-Chahine, thank you for your comments on our paper: ‘Comparison of drug-eluting and bare-metal stents in patients with diabetes undergoing primary percutaneous coronary intervention: what is the evidence?’ [1].

Percutaneous coronary intervention (PCI) is the preferred method of revascularization in the management of acute ST elevation myocardial infarction (STEMI). However, in a specific subset of patients, CABG may be appropriate.

For example, coronary angiography may reveal anatomy that is unsuitable for balloon angioplasty or stenting. In these patients, CABG may be indicated for the treatment of acute STEMI.

Furthermore, CABG is indicated when primary PCI has failed to achieve reperfusion of the myocardium in addition to persistent hemodynamic instability or life-threatening ventricular arrhythmia due to extensive ischemia (left main or 3-vessel disease). There are several limitations to CABG in the management of acute STEMI.

It has been shown that CABG performed within 2 days of hospitalization for acute STEMI is associated with a higher incidence of mortality in comparison to CABG carried out 3 or more days after acute STEMI [2].

The incidence of Rethoracotomy is significantly greater when CABG is performed within the first 3 days following acute STEMI in contrast to CABG carried out between day 4 and 30 [3]. Furthermore, post-operative intra-aortic balloon pump devices are required for longer, there is a higher incidence of bleeding complications, more inotropic drugs are required and there is a longer intensive care and total hospital stay when CABG is carried out within 3 days of presentation.

When compared against PCI, CABG is associated with a higher risk of stroke within the 30 day post-operative period [4].

References

[1] Gollop ND, Henderson DB, Flather MD. Interact Cardiovasc Thorac Surg. 2014 Jan; 18 (1): 112-6. In diabetic patients does the utilization of Drug Eluting Stents (DES) instead of Bare Metal Stents (BMS) reduce restenosis rate without compromising the efficacy and safety of Primary Percutaneous Coronary Intervention? [2] Weiss ES, Chang DD, Joyce DL, Nwakanma LU, Yuh DD. J Thorac Cardiovasc Surg. 2008 Mar; 135 (3): 503-11, 511.e1-3. Optimal timing of coronary artery bypass after acute myocardial infarction: a review of California discharge data. [3] Gu YL, van der Horst IC, Douglas YL, Svilaas T, Mariani MA, Zijlstra F. Neth Heart J. 2010 Aug; 18 (7-8): 348-54. Role of coronary artery bypass grafting during the acute and subacute phase of ST-elevation myocardial infarction. [4] Palmerini T, Biondi-Zoccai G, Riva DD, Mariani A, Savini C, Di Eusanio M, Genereux P, Frati G, Marullo AG, Landoni G, Greco T, Branzi A, De Servi S, Di Credico G, Taglieri N, Williams MR, Stone GW. Am Heart J. 2013 Jun; 165(6) :910-917.e14. Risk of stroke with percutaneous coronary intervention compared with on-pump and off-pump coronary artery bypass graft surgery: Evidence from a comprehensive network meta-analysis.

On 2014 Jan 18, Jamil Hajj-Chahine commented:

I read with great interest the paper by Gollop et al regarding the best available stenting technology for diabetic patients undergoing percutaneous coronary intervention [1]. After reviewing the relevant literature, they concluded that drug-eluting stents are superior to bare- metal stents in this subset of patients with regard to clinical outcomes.

I would like to take the opportunity to discuss the place of coronary artery bypass grafting (CABG) in the era of drug-eluting stent for diabetic patients with multi-vessel coronary disease. CABG was shown to be more beneficial than bare-metal stent for patients with diabetes and multi -vessel disease [2]. However, the improvement in restenosis rate with drug -eluting stents has accelerated the wide use of stenting in patients with extensive coronary disease and extended to include patients with diabetes. Reports mainly from retrospective studies showed that CABG is the preferred modality of treatment in diabetic patients with multi-vessel disease [3-4].

In 2012, the results of FRREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial were published [5]. This international trial was specially designed to include only patients with diabetes. Freedom trial randomly assigned 1900 patients in140 centres to undergo either percutaneous coronary intervention with drug-eluting stents or CABG. The primary outcome was a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke and it did not include the need for repeat revascularization. The primary end point occurred more frequently in the interventional group 26,6% compared with CABG group 18,7% (p=0,005) at five years post-procedure. CABG in patients with diabetes and multi- vessel disease reduced significantly the rates of death and myocardial infarction. However, stroke rate was the major drawback of surgery with 5- year rates of 2.4% in the stenting group and 5.2% in the CABG group (P=0.03).

In this subset of high-risk patients, we can conclude that the substantial survival advantage of surgery is still valid even in the era of drug-eluting stents.

References

[1] Gollop ND, Henderson DB, Flather MD. Comparison of drug-eluting and bare-metal stents in patients with diabetes undergoing primary percutaneous coronary intervention: what is the evidence? Interact Cardiovasc Thorac Surg. 2013 doi:10.1093/icvts/ivt454.

[2] Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI). Circulation. 1997;96:1761-9.

[3] Yang JH, Gwon HC, Cho SJ, Hahn JY, Choi JH, Choi SH, et al. Comparison of coronary artery bypass grafting with drug-eluting stent implantation for the treatment of multivessel coronary artery disease. Ann Thorac Surg. 2008;85:65-70.

[4] Hueb W, Gersh BJ, Costa F, Lopes N, Soares PR, Dutra P, et al. Impact of diabetes on five-year outcomes of patients with multivessel coronary artery disease. Ann Thorac Surg. 2007;83:93-9.

[5] Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al; FREEDOM Trial Investigators. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367:2375- 84.

On 2014 Jan 18, Jamil Hajj-Chahine commented:

I read with great interest the paper by Gollop et al regarding the best available stenting technology for diabetic patients undergoing percutaneous coronary intervention [1]. After reviewing the relevant literature, they concluded that drug-eluting stents are superior to bare- metal stents in this subset of patients with regard to clinical outcomes.

I would like to take the opportunity to discuss the place of coronary artery bypass grafting (CABG) in the era of drug-eluting stent for diabetic patients with multi-vessel coronary disease. CABG was shown to be more beneficial than bare-metal stent for patients with diabetes and multi -vessel disease [2]. However, the improvement in restenosis rate with drug -eluting stents has accelerated the wide use of stenting in patients with extensive coronary disease and extended to include patients with diabetes. Reports mainly from retrospective studies showed that CABG is the preferred modality of treatment in diabetic patients with multi-vessel disease [3-4].

In 2012, the results of FRREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial were published [5]. This international trial was specially designed to include only patients with diabetes. Freedom trial randomly assigned 1900 patients in140 centres to undergo either percutaneous coronary intervention with drug-eluting stents or CABG. The primary outcome was a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke and it did not include the need for repeat revascularization. The primary end point occurred more frequently in the interventional group 26,6% compared with CABG group 18,7% (p=0,005) at five years post-procedure. CABG in patients with diabetes and multi- vessel disease reduced significantly the rates of death and myocardial infarction. However, stroke rate was the major drawback of surgery with 5- year rates of 2.4% in the stenting group and 5.2% in the CABG group (P=0.03).

In this subset of high-risk patients, we can conclude that the substantial survival advantage of surgery is still valid even in the era of drug-eluting stents.

References

[1] Gollop ND, Henderson DB, Flather MD. Comparison of drug-eluting and bare-metal stents in patients with diabetes undergoing primary percutaneous coronary intervention: what is the evidence? Interact Cardiovasc Thorac Surg. 2013 doi:10.1093/icvts/ivt454.

[2] Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI). Circulation. 1997;96:1761-9.

[3] Yang JH, Gwon HC, Cho SJ, Hahn JY, Choi JH, Choi SH, et al. Comparison of coronary artery bypass grafting with drug-eluting stent implantation for the treatment of multivessel coronary artery disease. Ann Thorac Surg. 2008;85:65-70.

[4] Hueb W, Gersh BJ, Costa F, Lopes N, Soares PR, Dutra P, et al. Impact of diabetes on five-year outcomes of patients with multivessel coronary artery disease. Ann Thorac Surg. 2007;83:93-9.

[5] Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al; FREEDOM Trial Investigators. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367:2375- 84.