The large-scale Acute Catheterization and Early Intervention Triage Strategy (ACUITY) trial showed that in patients with diabetes, acute coronary syndrome (ACS) and multivessel coronary artery disease, Percutaneous Coronary Revascularization (PCI) versus coronary artery bypass grafting (CABG) resulted in comparable rates of myocardial infarction, stroke, and death at 1-year follow-up.

The ACUITY trial evaluated the outcomes of diabetic patients with moderate and high-risk acute coronary syndrome and multivessel coronary artery disease managed with PCI versus CABG.

Among 13 819 moderate and high-risk ACS patients enrolled in the ACUITY trial, 1772 diabetic patients had multivessel disease with left anterior descending artery involvement and were managed by PCI (n=1349) or CABG (n=423). At 30 days, treatment with PCI compared with CABG was associated with lower rates of major bleeding (15.3% versus 55.6%; P<0.0001), blood transfusions (9.2% versus 43.2%; P<0.0001), and acute kidney injury (13.4% versus 33.6%; P<0.0001). PCI patients however had more unplanned revascularization procedures (6.9% versus 1.9%; P=0.03) and higher rates of repeat revascularization procedures (19.5% versus 5.2%; P=0.0001) at one year follow up. Rates of myocardial infarction, stroke, and death were non-significantly different at either 30 days or 1 year follow up.

REFERENCES

Surgical Versus Percutaneous Coronary Revascularization for Multivessel Disease in Diabetic Patients With Non-ST-Segment-Elevation Acute Coronary Syndrome: Analysis From the Acute Catheterization and Early Intervention Triage Strategy Trial; Ben-Gal Y, Mohr R, Feit F, Ohman E, Kirtane A, Xu K, Mehran R, Stone G; Circulation. JunE 15. pii: JIC2015615-3. [Epub ahead of print]

PMID: 26121708 Cardiovascular Interventions 2015; 8:

Cardio Debate Expert Comments

The ACUITY Sub-study comparing PCI and CABG (non-randomized) in moderate to high risk ACS patients with diabetes certainly gives Interventionalists confidence that PCI in such patients has good short term outcome.  Albeit there is a price to pay, ie, increased planned and unplanned revascularization procedures. Nearly a quarter of those who had PCI had repeat PCI within the year, but without excess myocardial infarction, stroke, and death. Arguably repeat PCI procedure is to be expected as it’s not common practice to completely revascularize all vessels in one sitting due to anatomical complexity, dye load and avoiding prolonged procedures. CABG deals with multi-vessel grafting at the same time.

On the other hand, in the longer term CABG does offer survival benefits in stable diabetic patients. The Freedom Trial which has 5-year follow up data suggests that PCI has 13 times more events. This is an impossible biological barrier for PCI to overcome irrespective of any future progress in techniques or stent technology. It’s a pharmacological challenge to neutralise the aggressive nature of coronary artery disease progression in diabetics. CABG bypasses “disease progression” and it has not exactly stood still in the meantime. The off-pump technique with full arterial revascularization if done well will offer superior results, but this is by no means widely available, neither is it used against PCI in any comparative trials. Hence PCI is here to stay for diabetics with multi-vessel disease.