Monday, November 30, 2009

REVASCULARISATION IN DIABETICS WITH 3VD-CAD ; PCI OR CABG

It has been debated for along time. Which is the prefered strategy for diabetics who require revascularisation, PCI or CABG ? Eversince the advent of balloon angioplasty, all the clinical trial data ( right from BARI, in the beginning ) have always favoured CABG. But the reality is that most diabetics prefer a lesser invasive strategy like angioplasty. So clinical trials keep getting done, as the gold post keeps changing ( in the beginning, we only had balloons, and then bare-metal stents, and now drug-eluting stents ).
The November 25th online edition of the Journal of the American College of Cardiology published the results of the CARDIA ( Coronary Artery Revascularisation in Diabetes ) study. The results of this study ( from continental Europe ) was initially presented at the European Congress of Cardiology in Munich in 2008. I suppose it took along time to come out because it is from this side of the pond and also because, although they planned to enrolled 600 patients into the study, they finally only managed 510. As this was a non-inferiority study, it may affect the statistics a little. Nontheless, the final conclusion by the authors led by Dr Anil Kapur of UK was that in diabetics with 3VD-CAD, PCI ( even with drug-eluting stents ) was inferior to CABG. The results somewhat mirror that of the SYNTAX trial. The clinical events at 1 year were basically the same on both arms apart from the need for repeat revascularisation, which wer clearly more often in the PCI arm. The CABG arm suffered from a higher incidence of strokes. We have heard all these findings before. They are amazingly consistent.
If you are diabetic and you require revascularisation, you should go for CABG, but you would run the risk of a stroke. If you should choose PCI, know that you may need more then one procedure within a year ( DES or not ).
I have always wondered how the results will pen out, if we sebset the patients into their severity and mode of treatment. There are diabetics and there are diabetics. Those on Insulin as opposed to those on medical therapy? Those with renal dysfunction as opposed to those without renal dysfunction. Also, as the goal post changes, does the second generation DES make a difference? Will thin strut cobalt-chromium be bettered? Will polymerless be better?
I suppose no clinical trial can answer all the questions, as disease understanding changes and as treatment modality changes. Maybe that is why there is still a need for clinicians and clinical judgements. But sometimes insurance and third party payers who follow guidelines cannot understand this.