Coronary Artery Bypass Preferable for T1D with Multivessel Disease

Coronary artery bypass surgery is the best option for most patients with type 1 diabetes who have multiple atherosclerotic coronary arteries, according to new data.

The study, led by Martin Holzmann (pictured), MD, PhD, of the Karolinska Institutet, in Stockholm Sweden, is significant because previous guidelines that called for the use of coronary artery bypass grafting (CABG) for patients with diabetes did not differentiate between type 1 and type 2 diabetes, despite the differences between them.

This left doctors treating patients with the less-common T1D without a clear picture of whether CABG or percutaneous coronary intervention (PCI) would be preferable in most instances.

The Karolinska team followed up on every case of a T1D patient undergoing a revascularization procedure in Sweden between 1995 and 2013. What they found was that after 10 years, patients who underwent PCI were 45% more likely to die of heart disease and had a 47% higher chance of myocardial infarction. They also found patients undergoing PCI were five times more likely to need a second procedure, either PCI or CABG.

Holzmann told MD Magazine that the findings were roughly what he expected based on previous research that involved both T1D and T2D patients.

“They are in line with what has been found in previous randomized controlled trials like the FREEDOM study which probably included only 5% to 10% type 1 diabetes patients,” Holzmann said. “As a matter of fact, the event rate was very similar in the PCI group in our study to the event rate found in the FREEDOM study. We believe that our findings extend previous findings from RCTs to also include type 1 diabetes patients.”

The findings have the potential to help reverse what Holzmann and colleagues found to be a dramatic decline in the proportion of patients undergoing CABG. Over the years encompassed in the research, the less-invasive PCI became the dominant procedure, Holzmann said.

In fact, between 1995 and 2000, 58% of T1D patients in Sweden who had at least two diseased coronary vessels underwent CABG. But by 2007-2013, only 5% of T1D patients had CABG instead of PCI.

Holzmann said his study shouldn’t be read to suggest that CABG is right for every patient with T1D. However, he suggests that it should cause for physicians and hospitals to give more consideration to CABG than they have in recent years. He suggests hospitals should create multispecialty “heart teams” who can carefully discuss the pros and cons of each procedure for each individual diabetic patient.

“I think that patients who run a high risk of dying in the early postoperative period should not undergo CABG,” he said. However, he said that’s likely to be a very small number of patients, thus, using a “heart team” evaluation approach would likely result in a higher rate of CABG procedures, and ultimately in lower rates of further problems.

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