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CABG superior to PCI in diabetics with multivessel CAD (FREEDOM)


 

Clinical question

For patients with diabetes and multivessel coronary artery disease, which revascularization strategy provides better outcomes?

Bottom line

Revascularization using coronary artery bypass grafting (CABG), as compared with percutaneous coronary intervention (PCI), significantly reduces long-term mortality as well as decreases the rate of myocardial infarctions in diabetic patients with multivessel coronary artery disease (CAD). The number needed to treat is 13. Of note, patients who undergo CABG are more likely to have a stroke, but this occurs mostly during the 30-day period following the procedure. LOE = 1b-

Reference

Farkouh ME, Domanski M, Sleeper LA, et al, for the FREEDOM Trial Investigators. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012 Nov 4 [Epub ahead of print].

Study Design

Randomized controlled trial (nonblinded)

Funding Source

Industry + govt

Allocation

Concealed

Setting

Inpatient (any location)

Synopsis

Using concealed allocation, these investigators enrolled 1900 patients with diabetes and multivessel CAD to receive either PCI with drug-eluting stents or CABG surgery. Most enrolled patients were men, had a mean age of 63 years, and 83% of the total group had evidence of 3-vessel disease. The use of appropriate cardiac medications, including statins and beta-blockers, was similar in the 2 groups, although patients in the PCI group were more likely to receive thienopyridines such as clopidogrel after 5 years of follow-up. Analysis was by intention to treat. Five years after revascularization, the primary composite outcome of all-cause mortality, nonfatal myocardial infarction, or nonfatal stroke was more likely in the PCI group than in the CABG group (26.6% vs 18.7%; P = .005). This was due to increased rates of death and myocardial infarction in the PCI group (for death: 16.3% vs 10.9%; P = .049; for MI: 13.9% vs 6%; P < .001). The CABG group did, however, have a higher rate of stroke at 5 years (5.2% vs 2.4%; P = .03). The majority of these strokes occurred during the first 30 days following revascularization.

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