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394 Percutaneous Coronary Intervention in The Management of Multi-Vessel CAD
in Diabetics - is There Still A Role After Freedom Trial

should be an initial strategy, with revascularization in rates of both myocardial infarction (P<0.001) and
needed in 1 out of every 2 or 3 patients. death from any cause (P=0.049). Stroke was more
frequent in the CABG group, with 5-year rates of
SYNTAX trial(14)randomly assigned 1800 patients 2.4% in the PCI group and 5.2% in the CABG group
with three-vessel or left main coronary artery disease (P=0.03). There was increased all-cause mortality in
to undergo CABG or PCI (in a 1:1 ratio). For all these the PCI group (P=0.049), with 5-year rates of 16.3% in
patients, the local cardiac surgeon and intervention- the PCI group versus 10.9% in the CABG group, for an
al cardiologist determined that equivalent anatomi- absolute difference of 5.4 percentage points.
cal revascularization could be achieved with either
treatment.Rates of major adverse cardiac or cere- In patients with a low SYNTAX score (i.e., ≤22),
brovascular events at 12 months were significantly there was a minimal difference in long-term clini-
higher in the PCI group (17.8%, vs. 12.4% for CABG; cal outcomes between cardiac surgery and PCI with
P=0.002), in large part because of an increased rate first-generation drug-eluting stents.
of repeat revascularization (13.5% vs. 5.9%, P<0.001). BEST Trial(16)randomized multi-vessel CAD patients
At 12 months, the rates of death and myocardial in- to CABG vs PCI with 2 generation Everolimus stents.
nd
farction were similar between the two groups. How- 40% of these patients had diabetes.During long-term
ever stroke was significantly more likely to occur with follow-up, the primary end point occurred more fre-
CABG (2.2%, vs. 0.6% with PCI; P=0.003).
quently in the PCI group than in the CABG group
Patients were categorized into low (<22), intermediate (15.3% vs. 10.6%; hazard ratio, 1.47; 95% CI, 1.01 to 2.13;
(23-32) and high (>33) score based on their coronary P=0.04). This difference was attributed largely to the
anatomy.In the CABG group, the binary 12-month preponderance of events of any repeat revasculariza-
rates of major adverse cardiac or cerebrovascular tion in the PCI group. Importantly rate of Death, stroke
events were similar among patients with low SYN- or MI did not defer between the two groups. Among
TAX scores (0 to 22, 14.7%) to those with interme- patients with diabetes, the rate of the primary end
diate scores (23 to 32, 12.0%), and those with high point was significantly higher among those assigned
scores (≥33, 10.9%). In contrast, in the PCI group, the to PCI than among those assigned to CABG (19.2%
rate of major adverse cardiac or cerebrovascular vs. 9.1%, P=0.007)
events was significantly increased among patients
with high SYNTAX scores (23.4%) as compared with Revascularization of patients with Diabetes
those with low scores (13.6%) or intermediate scores Taken altogether treatment of DM patients with MVD
(16.7%) (P=0.002 for high vs. low scores; P=0.04 for and SYNTAX score > 23 remains in the domain of
high vs. intermediate scores) cardiac surgery as primary treatment.
At 5 years the overall adverse-event rate was low- It perhaps is not unreasonable to offer CABG as the
er with CABG (27%) than with PCI (37%; P<0.001). primary revascularization modality when a patient
However, neither all-cause mortality nor stroke rate with DM develops 3 VD based on the FREEDOM tri-
differed significantly between the two groups. The al. Strategy of offering patients with Diabetes CABG
rates of MI and repeat revascularization were higher early particularly when there is limited plaque burden,
with PCI than with CABG (9.7% vs. 3.8% and 26% vs. runs the risk of grafts failing in the long term. On the
14%, respectively).In patients with SYNTAX scores ≥33, other hand if CABG is offered too late, perioperative
the overall adverse-event rate was 27% with CABG risks increase due to co-morbidities and too diffuse
and 44% with PCI, including a statistically significant CAD will preclude graft placement, thereby losing the
absolute increase in all-cause mortality of about 8% mortality benefit of CABG over PCI.
with PCI.
In addition to anatomical disease and clinical fac-
Only about 25% of the patients enrolled were medi- tors, some non-clinical factors may influence choice
cally treated Diabetics. of therapy. For example- socio-economic status, pa-

FREEDOM trial (15)coronary-artery bypass grafting tientswishes, operator skill, cultural acceptance and
(CABG randomnly assigned patients with diabetes resource availablilty.
and multivessel coronary artery disease to undergo Multi-disciplinary team approach to management of
either PCI with first generation drug-eluting stents these complex patients while inconvenient may help
or CABG. The primary outcome occurred more fre- management of these patients.
quently in the PCI group (P=0.005), with 5-year rates
of 26.6% in the PCI group and 18.7% in the CABG
group. The benefit of CABG was driven by differences

GCDC 2017