Nei diabetici con cardiopatia ischemica la
rivascolarizzazione con CABG è sempre
superiore?
Prof. F. Romeo
University of Rome“Tor Vergata”
Department of Cardiology
Atherosclerosis in Diabetes Mellitus:
Pathophysiologic Considerations
Abnormal platelet function
 activation and adhesion in response to shear stress
 expression of GpIIb/IIIa receptors  aggregation
More diffuse atherosclerosis pattern
Impaired coronary flow reserve reduced tolerance of
embolization
 plaque burden and more lipid-rich plaques
predisposed to rupture
Impaired ability to develop collaterals larger MIs
Increased response to vascular injury
 rates of restenosis and reocclusion following both
balloon angioplasty and bare stent implantation
Diabetes
It has been shown that Apolipoprotein A-I, the major protein component of
serum high-density lipoproteins, inhibits DC differentiation and maturation
TLR expression patterns can induce distinct types of vascular
inflammation as result of selective susceptibility of different regions of
the vascular tree to atherosclerosis
PPAR-a agonists ciglitazone and fenofibrate also inhibit oxLDL-induced
maturation and immune functions of DCs in vitro
Advanced glycosylation end products can promote atherosclerosis by
inducing maturation of
Patients with diabetes mellitus
Increased incidence of CAD
More extensive disease at angiography
Worse prognosis than non-diabetic CAD
>20% of all revascularisation procedures
Revascularisation in Diabetes Mellitus
Heartwire (www.theheart.org) Nov 1999
“Despite stents, diabetic patients undergoing
PCI still face higher death rates.”
AHA Scientific Statement 1999
“Recent studies indicate that coronary
angioplasty is less efficacious for patients with
diabetes than for those without; these reports
further reveal that CABG is the preferred
therapy in patients with diabetes when invasive
management is required.”
The 1991 Guidelines for CABG state that:
“the evidence is complete that the coronary artery bypass
operation relieves angina in most patients”.
Some caution must be expressed in the use of
CABG for relief of symptoms.
CABG treats the manifestations of CAD, not the
disease of process.
The second important recommendation for
CABG, after relief of symptoms, is
prolongation of life.
The explosive growth of PCI in the
last decade mandates a careful
examination of CABG survival
versus PCI survival
BARI: Impact of Diabetes on Survival
balloon angioplasty era
5 year survival
BARI Subgroups
Diabetic subgroup
(p=0.006)
CABG
PTCA
• Treated diabetic pts only
subgroup to show
significant survival
advantage with CABG
• 5 year survival
• CABG 81%
• PTCA 65%
NEJM 1996;335:217-25
PCI v CABG Trials - DM Subgroup Analyses
ARTS trial - stent era
1205 patients - DM 208 (17%)
CABG
1 year mortality
PCI
3.1%
6.3%
1 year repeat revasc
12.4%
21.6%
3 year event free
81.3%
52.7%
Do Diabetics Have Increased Mortality
After Multivessel Stenting?
Study (yrs f/u)
BARI (8)
Type of
Study
N
Adjusted
Hazard Ratio
RCT
353
1.87 *
EAST (8)
Summary:
RCT do not 90
1.56
Stents
appear to have
BARI
registry (5)attenuated
Obs the mortality
339
1.29 of
significantly
advantage
Duke databank (6)
Obs
770
1.27
CABG in multivessel CAD
Emory databank (5)
Obs
889
1.35 *
NNE (2)
Obs
2766
1.49*
ARTS (3)
RCT
210
1.70
SOS (1)
RCT
142
>10
Yellow = Stent vs. CABG
* P<0.05
FREEDOM Trial
PRIMARY OUTCOME – DEATH / STROKE / MI
Death/Stroke/MI, %
30
PCI/DES
CABG
Logrank P=0.005
PCI/DES
20
CABG
10
5-Year Event Rates: 26.6% vs. 18.7%
0
0
1
2
3
4
5
Years post-randomization
6
Freedom from Event (%)
SYNTAX Score  22
(N=669)
100
90
80
70
60
50
40
30
20
10
0
23.2%
17.2%
5-Year Event Rates:
PCI/DES
CABG
0.0
1.0
2.0
3.0
4.0
SYNTAX Score 23-32
(N=844)
100
90
80
70
60
50
40
30
20
10
0
5.0
5-Year Event Rates:
100
90
80
70
60
50
40
30
20
10
0
0.0
27.2%
17.7%
PCI/DES
CABG
1.0
0.0
Years post-randomization
Freedom from Event (%)
Freedom from Event (%)
PRIMARY ENDPOINT – DEATH / STROKE / MI
TREATMENT / SYNTAX INTERACTION - p=0.58
2.0
3.0
4.0
Years post-randomization
SYNTAX Score  33
(N=374)
5-Year Event Rates:
30.6%
22.8%
PCI/DES
CABG
1.0
2.0
3.0
4.0
Years post-randomization
5.0
5.0
PCI in STEMI
is Here to Stay!
Several studies have compared
outcomes for CABG and PCI, but
most were done before the availability
of stentig, wich has revolutioned the
latter approach
Stent Availability…
Several studies have compared outcomes for CABG and PCI,
but most were done before the availability of stentig, wich
has revolutioned the latter approach
Approaches to Improve Late DES Outcomes
Approaches to Improve Late DES Outcomes
Current DES have appreciably improved safety and
efficacy profiles in ACS and stable CAD compared to
first generation devices, and outcomes are improved
by ischemia-guided PCI
By utilizing small amounts of a bioabsorbable
polymer, polymer-free systems, or fully bioabsorbable
stents, future generation DES will likely further reduce
stent thrombosis and improve late outcomes
CABG in Patients with Diabetes
CABG advantage depends on use of LIMA
 rates of procedure related morbidity
Renal failure
Wound infection
Sternal wound failure
Possible increased stroke risk
ARTS trial - 1 year CVA rate
CABG 6.3% PCI 1.8%
PCI or CABG?
PCI or CABG?
Procedure di rivascolarizzazione miocardica:
- PCI
- CABG
Non devono essere considerate alternative.
Bisogna infatti fornire al paziente entrambe le possibilità di
rivascolarizzazione.
Importanza di un Timing esatto
PCI or CABG?
Scelta in base a:
1.Anatomia coronarica
2.Età
3.Presentazione Clinica (Angina
Cronica Stabile, Sindrome
Coronarica Acuta, Presenza di
Diabete)
Angiographic Patency after CABG: experience from CLEVELAND CLINIC DATABASE
(565+511 days)
Khot u et al. Circulation 2004
Angiographic Patency after CABG: experience from CLEVELAND CLINIC DATABASE
(565+511 days)
Khot u et al. Circulation 2004
Angiographic Patency after CABG: experience from CLEVELAND CLINIC DATABASE
(565+511 days)
Khot u et al. Circulation 2004
MULTIVESSEL DISEASE
PCI or CABG?
Cardiologists and Cardiac Surgeons
should give both opportunities to the
patients!
Cardiologist must remember…
The importance to make a complete
revascularization
Always let a second surgery chance
Think in terms of prognosis in
the term of life expectancy
rather than immediate success
Surgeon must remember…
Surgical revascularization can be a
path of no return
Surgical treatment accelerates the
closing of the native circle
PCI has to be the first therapeutic
choice…
… when is possible!!!
Both must remember …
The two methods must be seen not one the
alternative of one another but
as a completation
to be used in a rational and sequential way
The way to think is not as
PCI vs CABG
but
How to make a good PCI…
…to have in the future the possibility to
make a good CABG
CABG performed in 1986
Female, 43 years, diabetic
One month later