Diabetes is one of the principle aetiological factors for coronary artery disease with vascular disease in diabetics displaying a particularly aggressive phenotype, often resulting in multivessel disease. Current evidence suggests that CABG is particularly beneficial in these patients as compared with PCI. however, much of this evidence was either gathered in the era before modern drug eluting stents or is from meta-analyses of smaller studies.

In order to update this evidence the large Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial randomized 1900 patients at 140 international centers with diabetes and multivessel coronary artery disease to undergo either PCI with drug-eluting stents or CABG. The patients’ mean age was 63.1±9.1 years, 29% were women, 83% had three-vessel disease, and approximately 30% were using insulin. Patients were followed for a minimum of 2 years (median 3.8 years) and the primary outcome measure was a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke.

The results strongly favoured surgery with 5-year rates of the primary outcome of 26.6% in the PCI group and 18.7% in the CABG group (P=0.005). 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) although the trial was not specifically powered to detect differences in the latter outcome. Stroke was more frequent in the CABG group with 5-year rates of 5.2% vs 2.4% in the PCI group (P=0.03), but the majority of these were peri-procedural and there was no significant difference maintained with time.

Conclusions:

For patients with diabetes and advanced coronary artery disease, in this large outcomes study CABG was superior to PCI, significantly reducing rates of myocardial infarction and all-cause mortality.

• Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, Yang M, Cohen DJ, Rosenberg Y, Solomon SD, Desai AS, Gersh BJ, Magnuson EA, Lansky A, Boineau R, Weinberger J, Ramanathan K, Sousa JE, Rankin J, Bhargava B, Buse J, Hueb W, Smith CR, Muratov V, Bansilal S, King S 3rd, Bertrand M, Fuster V; the FREEDOM Trial Investigators. Strategies for Multivessel Revascularization in Patients with Diabetes. N Engl J Med. 2012 Nov 4. [Epub ahead of print]