J Korean Med Sci.  2005 Apr;20(2):196-203. 10.3346/jkms.2005.20.2.196.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Diabetics with Multivessel Coronary Artery Disease: The Korean Multicenter Revascularization Registry (KORR)

• Gwon HC
• Choi SH
• Choi BI
• Cho SY
• Ro YM
• Lee WR
• KORR Investigators

• KMID: 1095189
• DOI: http://doi.org/10.3346/jkms.2005.20.2.196

Abstract

This study was designed to assess the relative merits of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD), particularly for Korean diabetics. Among 3,279 patients with MVCAD who were recommended for revascularization were enrolled from nine centers in Korea, 2,154 were selected after statistical adjustments for the disparities between two groups. Survival rates were not significantly different for three years between two groups. Among diabetic patients, the three-year mortality rate in PCI group was 1.9-fold higher than that of CABG group, although it was not statistically significant (PCI 19.8%, CABG 11.4%, p=0.14). The three-year mortality rate was similar between the two groups in non-diabetics (PCI 8.3%, CABG 10.0%, p=0.50). The 30-day rate of cerebrovascular event was higher in CABG group, for both diabetic (CABG 3.6%, PCI 0.0%, p<0.001) and non-diabetic patients (CABG 2.4%, PCI 0.0%, p<0.001). Short- and long-term revascularization rates were higher in PCI group than in CABG group. As a conclusion, this Korean registry demonstrates that PCI was associated with comparable survival rates and lower short-term morbidity, but a greater requirement for repeated revascularization compared with CABG in Korean diabetics.

Keyword

Angioplasty, Transluminal, Percutaneous Coronary; Coronary Artery Bypass; Diabetes Mellitus; Long-term Risk; Myocardial Ischemia

MeSH Terms

*Angioplasty, Transluminal, Percutaneous Coronary
Comparative Study
*Coronary Artery Bypass
Coronary Disease/*therapy
Diabetic Angiopathies/*therapy
Humans
*Registries
Research Support, Non-U.S. Gov't
Retrospective Studies
Stents

Figure

• 

  Fig. 1 Kaplan-Meier curve for cardiovascular event (CVE). Survival rates are similar for the two revascularization strategies. Long-term morbidity (death, MI, or CVE) also dose not differ significantly, but the 30-day incidence of morbidity is significantly higher in the CABG group, mainly due to a higher incidence of CVE in that group. The infarct- or CVE-free survival rate without revascularization is much higher in the CABG group, due mainly to a lower revascularization rate.

• 

  Fig. 2 Clinical outcomes according to diabetic status and revascularization strategy. Mortality and morbidity are similar after CABG or PCI, both for treated diabetic and non-treated diabetic patients. For treated diabetic patients, however, the 30-day mortality rate is higher, whereas the three-year mortality rate is lower in the CABG group, although these differences are not statistically significant. The 30-day MI- or CVE-free survival rate is significantly higher in the CABG group due to the higher rate of CVE. MACE is significantly lower in the CABG group.

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  Fig. 3 Neither the mortality, morbidity, nor MACE rate is significantly different between the four diabetes treatment modality groups, in either the CABG or PCI groups. In the PCI group, treated diabetic patients had a higher risk of MACE.

Reference

1. Patil CV, Nikolsky E, Boulos M, Grenadier E, Beyar R. Multivessel coronary artery disease: current revascularization strategies. Eur Heart J. 2001. 22:1183–1197.

2. Rodriguez A, Boullon F, Perez-Balino N, Paviotti C, Liprandi MI, Palacios IF. Argentine randomized trial of percutaneous transluminal coronary angioplasty versus coronary artery bypass surgery in multivessel disease (ERACI): in-hospital results and 1-year follow-up. J Am Coll Cardiol. 1993. 33:1060–1067.

3. King SB 3rd, Lembo NJ, Weintraub WS, Kosinski AS, Barnhart HX, Kutner MH, Alazraki NP, Guyton RA, Zhao XQ. A randomized trial comparing coronary angioplasty with coronary bypass surgery. N Engl J Med. 1994. 331:1044–1050.

4. RITA Trial Participants. Coronary angioplasty versus coronary artery bypass surgery: the Randomized Intervention Treatment of Angina (RITA) trial. Lancet. 1993. 341:573–580.

5. CABRI Trial participants. Coronary Angioplasty vs. Bypass Revascularization Investigation (CABRI) results during the first year. Lancet. 1995. 346:1179–1183.

6. Hamm CW, Reimers J, Ischinger T, Rupprecht HJ, Berger J, Bleifeld W. A randomized study of coronary angioplasty compared with bypass surgery in patients with symptomatic multivessel coronary disease. N Engl J Med. 1994. 331:1037–1043.

7. Carrie D, Elbaz M, Puel J, Fourcade J, Karouny E, Fournial G, Galinier M. Five-year outcome after coronary angioplasty versus bypass surgery in multivessel coronary disease. Circulation. 1997. 96:II-1–II-6.

8. Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med. 1996. 335:217–225.

9. Fischman DL, Leon MB, Baim DS, Schatz RA, Savage MP, Penn I, Detre K, Veltri L, Ricci D, Nobuyoshi M, Cleman M, Heuser R, Almond D, Teirstein PS, Fish RD, Colombo A, Brinker J, Moses J, Shaknovich A, Hirshfeld J, Bailey S, Ellis S, Rake R, Goldberg S. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med. 1994. 331:496–501.

10. Serruys PW, DeJaegere P, Kiemeneij F, Macaya C, Rutsch W, Heyndrickx G, Emanuelsson H, Marco J, Legrand V, Materne P, Belardi J, Sigwart U, Colombo A, Goy JJ, Van Den Heuvel P, Delcan J, Morel M. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med. 1994. 331:489–495.

11. Rodriguez A, Bernardi V, Navia J, Baldi J, Grinfeld L, Martinez J, Vogel D, Grinfeld R, Delacasa A, Garrido M, Oliveri R, Mele E, Palacios I, O'Neill W. Argentine randomized study: coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple-vessel disease (ERACI II): 30-day and one-year follow-up results. J Am Coll Cardiol. 2001. 37:51–58.

12. Morrison DA, Sethi G, Sacks J, Henderson W, Grover F, Sedlis S, Esposito R, Ramanathan K, Weiman D, Saucedo J, Antakli T, Paramesh V, Pett S, Vernon S, Birjiniuk V, Welt F, Krucoff M, Wolfe W, Lucke JC, Mediratta S, Booth D, Barbiere C, Lewis D. Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial. Investigators of the Department of Veterans Affairs Cooperative Study #385, the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME). J Am Coll Cardiol. 2001. 38:143–149.

13. Serruys PW, Unger F, Sousa JE, Jatene A, Bonnier HJ, Schonberger JP, Buller N, Bonser R, van den Brand MJ, van Herwerden LA, Morel MA, van Hout BA. Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med. 2001. 344:1117–1124.

14. King SB III, Kosinski AS, Guyton RA, Lembo NJ, Weintraub WS. Eight-year mortality in the Emory Angioplasty versus Surgery Trial (EAST). J Am Coll Cardiol. 2000. 35:1116–1121.

15. Niles NW, McGrath PD, Malenka D, Quinton H, Wennberg D, Shubrooks SJ, Tryzelaar JF, Clough R, Hearne MJ, Hernandez F Jr, Watkins MW, O'Connor GT. Northern New England Cardiovascular Disease Study Group. Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study. J Am Coll Cardiol. 2001. 37:1008–1015.

16. Feit F, Brooks MM, Sopko G, Keller NM, Rosen A, Krone R, Berger PB, Shemin R, Attubato MJ, Williams DO, Frye R, Detre KM. Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. Circulation. 2000. 101:2795–2802.

17. Kurbaan AS, Bowker TJ, Ilsley CD, Sigwart U, Rickards AF. On behlf of the CABRI Investigators (Coronary Angioplasty versus Bypass Revascularization Investigation). Difference in the mortality of the CABRI diabetic and nondiabetic populations and its relation to coronary artery disease and the revascularization mode. Am J Cardiol. 2001. 87:947–950.

18. Barsness GW, Peterson ED, Ohman EM, Nelson CL, DeLong ER, Reves JG, Smith PK, Anderson RD, Jones RH, Mark DB, Califf RM. Relationship between diabetes mellitus and long-term survival after coronary bypass and angioplasty. Circulation. 1997. 96:2551–2556.

19. The Korean Diabetes Association. Epidemiology of Diabetes. Diabetics. 1998. 2nd ed. Seoul, Korea: Koryo Medical Co.;23–24.

20. The Korean Diabetes Association. Epidemiology of Diabetes. Diabetics. 1998. 2nd ed. Seoul, Korea: Koryo Medical Co.;26–28.

21. Sim DS, Jeong MH, Kim W, Rhew JY, Yum JH, Kim JH, Ahn YK, Cho JG, Park JC, Ahn BH, Kim SH, Kang JC. Long-term clinical outcomes in diabetics after coronary artery bypass surgery and coronary stenting. Korean J Med. 2003. 65:160–167.

22. Abizaid A, Costa MA, Centemero M, Abizaid AS, Legrand VM, Limet RV, Schuler G, Mohr FW, Lindeboom W, Sousa AG, Sousa JE, van Hout B, Hugenholtz PG, Unger F, Serruys PW. Arterial Revascularization Therapy Study Group. Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients: insights from the Arterial Revascularization Therapy Study (ARTS) trial. Circulation. 2001. 104:533–538.

23. Sousa JE, Costa MA, Abizaid AC, Rensing BJ, Abizaid AS, Tanajura LF, Kozuma K, Van Langenhove G, Sousa AG, Falotico R, Jaeger J, Popma JJ, Serruys PW. Sustained suppression of neointimal proliferation by sirolimus-eluting stents: one-year angiographic and intravascular ultrasound follow-up. Circulation. 2001. 104:2007–2011.

24. Morice MC, Serruys PW, Sousa JE, Fajadet J, Ban Hayashi E, Perin M, Colombo A, Schuler G, Barragan P, Guagliumi G, Molnar F, Falotico R. RAVEL study group. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med. 2002. 346:1773–1780.