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CABG Beats Angioplasty for Diabetics

The 1996 Bypass Angioplasty Revascularization Investigation (BARI) was a randomized trial that compared coronary artery bypass grafting (CABG) with angioplasty; patients with severely symptomatic and angiographically confirmed multivessel coronary artery disease that was amenable to both methods of revascularization were eligible. The results revealed only 1 significant difference between revascularization methods: 5-year mortality rates for diabetics who underwent CABG were about 50 percent lower than for diabetics who underwent angioplasty. To identify the potential mechanism of benefit for diabetics, the investigators now have conducted an in-depth analysis of data from the 3603 BARI patients who underwent revascularization within 3 months of study entry.

The cumulative 5-year mortality rate among the 641 diabetic patients was significantly higher than among the 2962 nondiabetic patients (20 percent vs. 8 percent), as was the incidence of Q-wave MI at 5 years (8 percent vs. 4 percent). Compared with angioplasty, CABG was associated with a markedly lower mortality risk among diabetics who experienced Q-wave MIs during follow-up (relative risk, 0.09; 95 percent CI, 0.03-0.29) and with a moderately lower risk among those who did not (RR, 0.65; CI, 0.45-0.94). As previously reported, CABG was not associated with higher survival rates among nondiabetic patients.

Comment: These results suggest that CABG is more effective than angioplasty for diabetics with multivessel disease. CABG was associated with higher rates of survival both for diabetics who experienced MIs during follow-up and for those who did not, although the protective effect on the former group was more profound. However, it is important to note that the BARI study was conducted before more recent technological advances in percutaneous coronary interventions.

— HM Krumholz

Published in Journal Watch Cardiology January 1, 2001

Citation(s):

Detre KM et al for the Bypass Angioplasty Revascularization Investigation Investigators. The effect of previous coronary-artery bypass surgery on the prognosis of patients with diabetes who have acute myocardial infarction. N Engl J Med 2000 Apr 6 342 989-997.

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