The FREEDOM trial demonstrated superiority of coronary artery bypass grafting (CABG)
for patients with diabetes mellitus (DM) and multivessel coronary artery disease (MV
CAD) as compared to percutaneous coronary intervention (PCI) with drug eluting stent
(PCI-DES). We sought to study the impact of the FREEDOM trial on clinical practice.
We studied trends in the use of CABG vs. PCI and factors associated with revascularization
strategy among 6,985 patients with concomitant CAD and MV CAD at 7 centers pre- and
post-trial (2008-2012 vs. 2013-2017) as well as hospital outcomes. Multivariable mixed
effects logistic regression was performed to identify risk factors associated with
choice of revascularization strategy among the patients with 3-vessel CAD (3V CAD).
41% of patients had 3V CAD and 18% were ≥75 years of age. While PCI-DES was the preferred
strategy in 2-vessel CAD (2V CAD), 72% of patients with 3V CAD underwent CABG. For
patients with 3V CAD, the ratio of CABG to PCI-DES procedures was 2.47 over the decade
and did not differ pre- and post-trial (adjusted odds ratio (OR) for CABG (vs. PCI)
1.01, 95% confidence interval (CI) 0.84-1.20). Independent risk factors of CABG among
patients with DM and 3V CAD included peripheral arterial disease and absence of prior
myocardial infarction and prior PCI. The risk factors for PCI were female sex (OR
0.60, 95% CI 0.50-0.73, p<0.001) and age ≥75 (OR 0.50, 95% CI 0.35-0.72, p<0.001).
Center based variability was observed for CABG vs. PCI (center effect, rho=14%, p<0.001).
In conclusion, PCI-DES is the preferred strategy for DM patients with MV CAD. Yet,
among those with 3V CAD, CABG was chosen in ¾ of patients with no change in clinical
practice related to the publication of the FREEDOM trial.
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Article info
Publication history
Published online: August 13, 2021
Received in revised form:
July 5,
2021
Received:
June 8,
2021
Footnotes
Trends in Revascularization for Patients with Diabetes
Funding: The Northern New England Cardiovascular Disease Study Group (NNECDSG) is a voluntary, multicenter, regional collaborative of interventional cardiology and cardiac surgery programs in northern New England. As a Quality Improvement focused registry, funding is provided directly by each hospital and independent of any industry or federal research grants.
Disclosures: Dr. Dauerman is currently a consultant to Sonogenix, Medtronic and Boston Scientific and has research grants from Medtronic and Boston Scientific. All other authors have no conflicts of interest to disclose.
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