Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting in Patients with Diabetic Nephropathy and Left Main Coronary Artery Disease.
BACKGROUND
Patients with diabetic nephropathy and unprotected left main (LM) coronary artery disease suffer from high cardiovascular morbidity and mortality. Although surgical revascularization is currently recommended in this special patient population, the optimal revascularization method for this distinct patient group has remained unclear.


METHODS
We collected 99 consecutive patients with unprotected LM disease and diabetic nephropathy, including 46 patients who had undergone percutaneous coronary intervention (PCI), and 53 who had coronary artery bypass grafting (CABG), with a mean age of 72 ± 10; with 80.8% male. Diabetic nephropathy was defined as overt proteinuria (proteinuria > 500 mg/day) and estimated glomerular filtration rate (eGFR) by the modified Modification of Diet in Renal Disease (MDRD) equation of less than 60 mL/min/1.73 m2. The baseline characteristics, angiographic results and long-term clinical outcomes were retrospectively analyzed.


RESULTS
The baseline characteristic of all patients were similar except for smokers, low density lipoprotein (LDL) level and extension of coronary artery disease involvement. The median follow-up period was 3.8 years. There were 73 patients (74%) considered as high risk with additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) ≥ 6. During follow-up period, the long term rate of all-cause death (PCI vs. CABG: 45.7% vs. 58.5%, p = 0.20) and all-cause death/myocardial infarction (MI)/stroke (PCI vs. CABG: 52.2% vs. 60.4%, p = 0.41) were comparable between the PCI and CABG group, whereas the repeat revascularization rate was significantly higher in the PCI group (PCI vs. CABG: 32.6% vs. 9.4%, p < 0.01). eGFR remained an independent predictor for all-cause death [hazard ratio: 0.97, 95% confidence interval: 0.96 to 0.99; p = 0.002] in multivariate logistic regression.


CONCLUSIONS
In the real-world practice of high-risk patients with unprotected LM disease and diabetic nephropathy, we found that PCI was a comparable alternative to CABG in terms of long-term risks of all-cause death/MI/stroke, with significantly higher repeat revascularization rate. Given the small patient number and retrospective nature, our findings should be validated by larger-scale randomized studies.
Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University.
Hsin-Ru
HR
Li
Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital; ; School of Medicine, National Yang-Ming University.
Chiao-Po
CP
Hsu
School of Medicine, National Yang-Ming University; ; Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Shih-Hsien
SH
Sung
Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital; ; School of Medicine, National Yang-Ming University.
Chun-Che
CC
Shih
School of Medicine, National Yang-Ming University; ; Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Shing-Jong
SJ
Lin
School of Medicine, National Yang-Ming University; ; Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Wan-Leong
WL
Chan
Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Cheng-Hsueh
CH
Wu
School of Medicine, National Yang-Ming University; ; Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Tse-Min
TM
Lu
Chronic kidney disease; Coronary artery bypass grafting; Diabetes mellitus; Diabetic nephropathy; Left main coronary artery disease; Percutaneous coronary intervention