Key result
2011 ACC/AHA guidelines fail to shift revascularization toward CABG over PCI in diabetic multivessel disease.
Why the study?
While CABG has a class I guideline recommendation for diabetes patients with chronic ≥3 vessel disease, data comparing the odds of receiving CABG versus PCI are limited.
Did the odds of performing CABG versus PCI increase after the 2011 ACC/AHA guidelines in patients with diabetes and ≥3 vessel coronary heart disease?
Observational (n=30,482)
Yes
Did the odds of performing CABG versus PCI increase after the 2011 ACC/AHA guidelines in patients with diabetes and ≥3 vessel coronary heart disease?
Despite Class I 2011 ACC/AHA guideline recommendations favoring CABG over PCI in diabetic patients with ≥3 vessel coronary disease, real-world clinical practice showed no significant increase in the odds of performing CABG relative to PCI.
Answers are grounded in this paper and cite their sources.
Guidelines failed to increase CABG use versus PCI in diabetic multivessel disease; leaves open questions on implementation barriers and real-world adherence.
In diabetes patients with chronic ≥3 vessel disease, coronary artery bypass grafting (CABG) holds a class I recommendation in the American College of Cardiology and American Heart Association (ACC/AHA) 2011 guidelines, and this classification has not changed to date. Much of the literature has focused upon whether CABG or percutaneous coronary intervention (PCI) produces better outcomes; there is a paucity of data comparing the odds of receiving these procedures. A secondary analysis was conducted in a de-identified database comprised of 30,482 patients satisfying the entry criteria. Odds of occurrence (CABG, PCI) were determined as the binary dependent variable in period 1, (17 October 2009 through 31 December 2011), and period 2 (1 January 2013 through 16 March 2015), before and after the 2011 guidelines, while controlling for gender, ethnicity/race, and ischemic heart disease as covariates. The odds of performing CABG rather than PCI in period 2 were not statistically significantly different than in period 1 (p = 0.400). The logistic regression model chi-square statistic was statistically significant, with χ2 (7) = 308.850, p < 0.0001. The Wald statistic showed that ethnicity/race (African American, Caucasian, Hispanic and Other), gender, and heart disease contributed significantly to the prediction model with p < 0.05, but ethnicity ‘Unknown’ did not. The odds of CABG versus PCI in period 2 were 0.98 times those in period 1 95% confidence interval (CI) = (0.925, 1.032), statistically controlling for covariates. There was no significant rise in the odds of undergoing a CABG among this dataset of high-risk patients with diabetes and multivessel coronary heart disease. Modern practice has evolved regarding patient choice and additional variables that impact the final revascularization method employed. The degree to which odds of occurrence of procedures are a reliable surrogate for provider compliance with guidelines remains uncertain.
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Rumana et al. (2019) conducted an observational in Diabetes mellitus with multivessel (≥3 vessel) coronary heart disease (n=30,482). Post-2011 ACC/AHA guideline period (Period 2: 1 January 2013 through 16 March 2015) vs. Pre-2011 ACC/AHA guideline period (Period 1: 17 October 2009 through 31 December 2011) was evaluated on Odds of undergoing coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) (OR 0.98, 95% CI 0.925, 1.032, p=0.400). Issuance of the 2011 ACC/AHA guidelines did not increase the odds of undergoing CABG versus PCI in diabetic patients with multivessel disease.
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