Medium to long-term patient-oriented effectiveness of surgical or percutaneous revascularization in diabetes and severe coronary artery disease

Background — In patients with diabetes and coronary artery disease, coronary artery bypass grafting (CABG) confers a long-term survival advantage over percutaneous coronary intervention (PCI); however, a knowledge gap remains regarding patient-centred outcomes. We therefore compared patient-defined adverse cardiovascular and noncardiovascular events (PACE) after CABG vs PCI in diabetic patients.

Methods — We conducted a population-based, retrospective cohort study of all diabetic patients who underwent CABG or PCI between October 2008 and December 2018 in Ontario, Canada. The primary outcome was PACE, defined as the composite of severe stroke requiring hospitalization > 14 days or inpatient rehabilitation, ventilator dependence, heart failure hospitalization, long-term care admission, and new-onset dialysis. Secondary outcomes included all-cause mortality and individual PACE components. Overlap weighting using propensity scores was performed to account for baseline differences between groups. Cumulative incidence functions were estimated, and groups were compared using cause-specific hazard models (with death as a competing risk) and Cox proportional hazards models.

Results — A total of 58,826 patients (25,751 CABG; 33,075 PCI) were followed for a mean of 4.7 years (standard deviation 3.1; maximum 11.5). Rates of PACE were lower after CABG vs PCI over 1-5 years postintervention (1-year HR 0.88 [95% CI 0.77-1.00]; 5-year HR 0.83 [95% CI 0.71-0.97]). Rates of death were lower after CABG during the first 8 years (30-day HR 0.61 [95% CI 0.50-0.74]; 5-year HR 0.71 [95% CI 0.63-0.80]; 8-year HR 0.82 [95% CI 0.69-0.98]).

Conclusions — We observed lower rates of PACE and all-cause mortality in diabetic patients within the first 5 years after CABG, compared to PCI. Findings could be used to inform shared decision-making to achieve outcomes most valued by patients.