Coronary Revascularization of Patients With Diabetes Mellitus in the Setting of Acute Coronary Syndromes.

October 8, 2019 1233 Lucas C. Godoy, MD Vivek Rao, MD, PhD Michael E. Farkouh, MD, MSc Diabetes mellitus (DM) is a global epidemic, and in North America, the number of patients with DM is expected to increase by 35% in the next 3 decades, according to the International Diabetes Federation. Cardiovascular disease is the leading cause of death in this population, and approximately onefourth of patients who develop an acute coronary syndrome (ACS) have DM. Compared with the general population, these patients have a more complex coronary anatomy (approximately two-thirds of them have multivessel disease [MVD]), a large burden of comorbidities (eg, hypertension, chronic renal disease, and heart failure), and a higher risk of developing stent-related complications, namely, stent thrombosis and restenosis. All these issues explain why patients with DM have a worse prognosis after an ACS. Improved diagnostic and therapeutic approaches developed recently have contributed to gradually reduce negative cardiovascular outcomes in this population, but concerns still exist regarding the optimal revascularization strategy in the ACS setting. A great deal of evidence exists comparing coronary artery bypass graft (CABG) surgery with percutaneous coronary intervention (PCI) in patients with DM and stable ischemic heart disease. In this setting, CABG may lead to a numerically greater upfront risk of cardiovascular events, particularly stroke, in the first days to months after the procedure, whereas in the long term, CABG is consistently associated with lower rates of myocardial infarction (MI) and repeat revascularization. The FREEDOM trial (Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease) showed a significant reduction in all-cause mortality, MI, and stroke in patients with DM who underwent CABG versus PCI, during a mean follow-up of 3.8 years (18.7% versus 26.6%, P=0.005). Over an extended follow-up of 7.5 years, CABG also led to reduced all-cause mortality (18.3% versus 24.3%, P=0.01). 1 A recently published meta-analysis with patientlevel data from 11 randomized clinical trials (including FREEDOM) demonstrated that compared with CABG, PCI led to a 48% increase in the 5-year rate of death in the population with DM (hazard ratio, 1.48; 95% CI, 1.19–1.84; P=0.0004). 2 In the ACS setting, conversely, PCI is the most frequently performed procedure. In patients with an ST-segment–elevation MI, primary PCI should be the revascularization method of choice, whenever available. Controversy still exists regarding when and how to deal with possible residual lesions. In the non–ST-segment– elevation ACS setting, recent observational data have suggested that systematic treatment with PCI may not be the best approach for patients with DM and MVD. Ramanathan and colleagues3 evaluated all revascularization procedures performed in patients with DM and MVD in the province of British Columbia, Canada, from 2007 through 2014. Particularly in the post-ACS setting (n=2947 patients), CABG, compared to PCI, was associated with a lower incidence of major adverse cardiac or cerebrovascular events (ie, all-cause mortality, MI, and stroke; 4.3% versus © 2019 American Heart Association, Inc. ON MY MIND