Treatment of Diabetic Patient with Multivessel Coronary Artery Disease: the Surgeon Perspective

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1 Treatment of Diabetic Patient with Multivessel Coronary Artery Disease: the Surgeon Perspective Fabio B. Jatene Full Professor of Cardiovascular Surgery Heart Institute - HC-FMUSP fabiojatene@incor.usp.br

2 Rationale The prevalence of diabetes mellitus is rising at an alarming rate and is projected to more than double by 2030 The disease currently afflicts 171 million people worldwide, with 23.6 million in the USA The adverse microvascular and macrovascular consequences of diabetes are well recognized, as is the accompanying accelerated rate of atherosclerosis that predisposes patients to coronary artery disease and to higher rates of myocardial infarction and death. Boden WE, Taggart DP. N Engl J Med Jun 11;360(24):2570-2

3 Rationale Treatment strategies that are aimed at reducing these events have embraced both optimal medical therapy (lifestyle intervention, vigilant glycemic control, and aggressive secondary prevention) and interventional management (catheter-based and surgical revascularization). Boden WE, Taggart DP. N Engl J Med Jun 11;360(24):2570-2

4 Evidences There was no significant long-term disadvantage regarding mortality or myocardial infarction associated with an initial strategy of PTCA compared with CABG. Among patients with treated diabetes, CABG conferred long-term survival benefit BARI Investigators. J Am Coll Cardiol Apr 17;49(15):1600-6

5 very long and sinuous road

6 What Have we Learned in this Journey?

7 All three therapeutic regimens resulted in high rates of cardiac-related deaths among patients with diabetes compared with patients without diabetes. Moreover, we observed better outcomes among patients with diabetes and multivessel coronary artery disease undergoing CABG regarding the primary endpoint at 5-year follow-up. Hueb WA et al. Ann Thorac Surg Jan;83(1):93-9.

8 Kaplan-Meier Estimates for Event Rates at 5 Years The BARI 2D Study Group. N Engl J Med 2009;360:

9 In the PCI stratum, there was no significant difference in primary end points between the revascularization group and the medical-therapy group. In the CABG stratum, the rate of major cardiovascular events was significantly lower in the revascularization group (22.4%) than in the medical-therapy group (30.5%, P=0.01; P=0.002 for interaction between stratum and study group). The BARI 2D Study Group. N Engl J Med 2009;360:

10 For patients with diabetes and advanced coronary artery disease, CABG was superior to PCI in that it significantly reduced rates of death and myocardial infarction, with a higher rate of stroke. N Engl J Med Dec 20;367(25):

11 The primary outcome was a composite of death from any cause, nonfatal AMI and nonfatal stroke - occurred more frequently in the PCI group (P = 0.005), with 5-year rates of 26.6% in the PCI group and 18.7% in the CABG group. The benefit of CABG was driven by differences in rates of both myocardial infarction (P<0.001) and death from any cause (P = 0.049). N Engl J Med Dec 20;367(25):

12 Stroke was more frequent in the CABG group, with 5-year rates of 2.4% in the PCI group and 5.2% in the CABG group (P = 0.03). Conclusion: For patients with diabetes and advanced coronary artery disease, CABG was superior to PCI in that it significantly reduced rates of death and myocardial infarction, however with a higher rate of stroke. N Engl J Med Dec 20;367(25):

13 How the CABG has improved its results?

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16 Diabetic patients usually have extensive CAD They require frequently multiple grafts Observational evidences suggest that both IMA improve outcomes, without compromising sternal stability

17 1. Bilateral internal thoracic artery grafting has been reported to provide better long-term results than single internal thoracic artery grafting

18 2. The risk of deep sternal wound infection can be minimized in diabetic patients undergoing CABG by performing ITA harvested in a skeletonized manner with meticulous attention to preserving sternal blood flow

19 3. In terms of postoperative complications and early and mid-term survival, off-pump CABG is very good technique, when possible, in diabetic patients

20 HEART TEAM multidisciplinary collaboration among the specialties to provide the best patientoriented care. The process of decision making and medical information of the patient must be guided by following the four principles of health ethics: autonomy, beneficence, nonmaleficence and justice. Goems WJ et al. Rev Bras Cir Cardiovasc 2010;25(4):VI-VII.

21 Final Remarks According to the evidences, currently, CABG is the appropriate procedure to treat diabetic patient with multivessel coronary artery disease There are mainly lower incidence of reoperation and late adverse effects in the evolution Cardiovascular surgeons are looking for the best technical approach, including: arterial grafts (bilateral internal thoracic artery grafting), off-pump CABG and skeletonized harvesting

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24 Evidences In the treated diabetes subgroup, patients assigned to CABG had significantly higher cardiac survival (p < 0.01) and trends for better survival and greater freedom from cardiac death or any MI (p < 0.05) BARI Investigators. J Am Coll Cardiol Apr 17;49(15):1600-6

25 Probability of survival free of cardiac-related death among diabetic patients Hueb WA et al. Ann Thorac Surg Jan;83(1):93-9.

26 Probability of event-free survival among diabetic patients Hueb WA et al. Ann Thorac Surg Jan;83(1):93-9.