Page 511 - fbkCardioDiabetes_2017

Stable Ischaemic Heart Disease in Diabetics : 487
Medical Therapy vs Revascularization

improve health status and survival; and death or MI with improved event-free survival in pa-
tients with significant reduction of ischaemia. Along
(5) Use coronary revascularization when there is clear the same line, patients with angina or exercise-in-
evidence of the potential to improve health status duced ischaemia early after MI had a better progno-
and survival.
sis after revascularization than with medical therapy
Trials have shown the survival benefit of CABG alone in the DANAMI study.
6
(compared to medical therapy alone) for the follow- Various observational studies have addressed the
ing group of patients:
impact of revascularization on prognosis. A myo-
LM disease ( VA Coop Study) cardial perfusion study of 10 627 patients without
prior CAD showed an increasing survival benefit of
3 vessel disease involves proximal LAD (European
Coronary Surgery Study) revascularization over medical treatment in patients
with moderate to severe ischaemia, whereas no such
3 vessel CAD with low EF (CASS) benefit was apparent in patients with only mild or
For more severe coronary artery disease absence of ischaemia. 7
(SYNTAX scores > 22 for 3-vessel disease and SYN- A meta-analysis of 24 studies encompassing 3088
TAX scores > 32 for left main disease), coronary ar- patients with left-ventricular dysfunction (mean LVEF
tery bypass grafting (CABG) offers a survival advan- = 32 ± 8%) who underwent assessment of viability by
tage as well as a reduced need for repeat intervention means of thallium perfusion imaging, F-18 fluoro-
at two years(Syntax trial). 3 deoxy glucose metabolic imaging, or Dobutamine

Revascularization, by eliminating the target stress echocardiography and were followed for a
lesion (PCI) or bypassing the narrowed epicardial ves- mean of 25 months. In patients with myocardial via-
sel (CABG), more effectively relieves myocardial isch- bility, revascularization was associated with an 80%
aemia than medical treatment alone. For example, reduction of risk-adjusted mortality compared with
in the randomized Asymptomatic Cardiac Ischemia medical treatment (16%/year vs. 3%/year). This benefit
Pilot (ACIP) study, 57% of patients treated with re- was most apparent in patients with impaired left-ven-
4
8
vascularization were free of ischaemia at 1 year com- tricular function.
pared with 31 and 36% in the ischaemia-guided and Recently, FFR was compared with angiography for
angina-guided strategies, respectively (P < 0.0001). guiding PCI in a large-scale randomized trial with
Furthermore, at 2 years follow-up, the risk of death 1005 patients (FAME). At 1 year, routine measure-
9
and MI was significantly lower among patients under- ment of FFR to select lesions requiring PCI (FFR <
going revascularization (4.7%) compared with those 80%) was associated with lower rates of death or MI
receiving ischaemia-guided (8.8%) or angina-guided than PCI guided by angiography alone. Similarly, de-
medical treatment (12.1%, P < 0.04).Similarly, patients ferring revascularization in patients with non-signifi-
with silent ischaemia after recent MI enrolled into cant lesions as determined by FFR appeared safe as
5
the randomized SWISSI II trial showed lower rates of shown during the 5 year follow-up of the randomized
ischaemia when allocated to PCI (12%) than medical DEFER study with similar rates of death or MI (<1%/
10
treatment (29%, P = 0.03), a beneficial effect accom- year) among patients treated medically and those un-
panied by improved left-ventricular ejection fraction dergoing PCI.
(57 vs. 49%, P < 0.001) and an absolute reduction
in clinical events (cardiac death, MI, and revascular- Coronary Revascularization Considerations
ization) of 6.3% per year in favour of PCI. Along the Percutaneous Coronary Intervention In
same line, patients with angina or exercise-induced
ischaemia early after MI had a better prognosis af- Diabetes
ter revascularization than with medical therapy alone The optimal strategy of coronary revascularization
in the DANAMI study. In the myocardial perfusion for patients with diabetes remains controversial. Al-
6
substudy of COURAGE, PCI compared with medical though initial success rates in diabetic and nondi-
treatment showed a greater absolute reduction in abetic patients are similar, diabetic patients exhibit
myocardial ischaemia (−2.7 vs. −0.5%, P < 0.0001), and higher restenosis rates after PCI and worse long-term
more patients exhibited a relevant reduction in isch- outcomes.A variety of metabolic and anatomic ab-
aemia (33 vs. 19%, P = 0.0004), particularly among normalities associated with diabetes and a greater
those with moderate to severe ischaemia (78 vs. 52%, degree of plaque burden may contribute to resteno-
P = 0.007).Again, there was a graded relationship be- sis in diabetic patients. Although drug-eluting stents
tween reduction of ischaemia and subsequent risk of have reduced the need for target lesion revascular-

Cardio Diabetes Medicine