Coronary Revascularization in the Diabetic Patient

Johanne Silvain, Jean-Baptiste Vignalou, Olivier Barthlmy, Mathieu Kerneis, Jean-Philippe

Collet and Gilles Montalescot
Circulation. 2014;130:918-922
doi: 10.1161/CIRCULATIONAHA.113.004382
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2014 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539

The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circ.ahajournals.org/content/130/11/918

Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published
in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial
Office. Once the online version of the published article for which permission is being requested is located,
click Request Permissions in the middle column of the Web page under Services. Further information about
this process is available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Circulation is online at:
http://circ.ahajournals.org//subscriptions/

Downloaded from http://circ.ahajournals.org/ by guest on September 14, 2014

Clinician Update

Coronary Revascularization in the Diabetic Patient

Johanne Silvain, MD, PhD; Jean-Baptiste Vignalou, MD; Olivier Barthlmy, MD;
Mathieu Kerneis, MD; Jean-Philippe Collet, MD, PhD; Gilles Montalescot, MD, PhD

Case Presentation
An asymptomatic and sedentary
58-yearold man with moderate overweight (body mass index, 29 kg/m2)
and controlled hypertension was
referred for a stress test. The patient
had a highly positive stress test, with
significant ST segment depression and
tightening chest pain 2 minutes after the
start of the exercise (40 Watts) followed
by nonsustained ventricular tachycardia at rest. The physician hospitalized
the patient into the coronary care unit
for further evaluation. The echocardiogram was considered normal, without
wall motion abnormalities, and serial
troponin measurements remained normal. The patient was scheduled for next
day coronary angiogram. In the morning, the laboratory evaluation included
a fasting blood glucose value of 135
mg/dL, with a hemoglobin A1C of
7.4%, resulting in the likely diagnosis
of previously unknown type 2 diabetes
mellitus. Renal function was normal.
The coronary angiogram showed a
right-sided dominant coronary anatomy, with a focal lesion (75%) of the
mid right coronary artery and with a
fractional flow reserve (FFR) measured
at 0.65. There were 2 focal and severe
lesions in the left anterior descending

artery (LAD), 1 proximal (95%) just

before the first diagonal branch, which
had also an intermediate ostial lesion,
and 1 less tight lesion downstream
(70%). FFR was not performed on the
LAD because of the critical nature of
the proximal lesion. The circumflex
artery was a small artery without major
branches. How would you manage this
patient?

Background
Diabetes Mellitus and Coronary
Artery Disease
Cardiovascular disease is the leading cause of morbidity and mortality in people with diabetes mellitus.
Patients with diabetes mellitus have a
2- to 4-fold increase in risk of developing cardiovascular disease than
those without diabetes mellitus, and
also a 2- to 5-fold increase in mortality attributable to cardiovascular disease when compared with age- and
sex-matched nondiabetic persons.1
Accelerated atherogenesis, blood
abnormalities (altered platelet function, inflammation, hypofibrinolysis,
and hypercoagulability), and myocardial vulnerability in diabetic patients
are now considered as the causative

factors for life-threatening cardiovascular events.2

In coronary artery disease (CAD),
atherosclerotic plaques can cause damage either with progressive evolution of
the plaque volume leading to the narrowing of the lumen of the coronary
arteries with subsequent ischemia, or
with an unstable fissured plaque triggering local thrombosis, leading to an
acute coronary syndrome.
Primary and secondary prevention
of CAD remain unmet therapeutic
challenges in diabetic patients. Drug
management of CAD has evolved
similarly for diabetic and nondiabetic
patients, although the risk of complications and the long-term prognosis differ (Table1).

Discovery of CAD in a Diabetic

Patient
The presence of symptoms (typical angina or equivalents) in patients
with type 2 diabetes mellitus has been
associated with worse outcomes than
in nondiabetic patients because it may
indicate severe CAD. Silent myocardial
ischemia discovered through resting
ECG abnormalities, wall motion abnormalities in echocardiography, screening ischemic stress test, or FFR during

From the ACTION Coeur Research Group, Institut de Cardiologie, Piti-Salptrire Hospital (APHP), Sorbonne Universits, (UPMC), INSERM,
UMRS 1166, Paris, France.
Correspondence to Gilles Montalescot, MD, PhD, Bureau 236, Institut de Cardiologie, Piti-Salptrire University Hospital, 4783 bld de lHpital,
75013 Paris, France. E-mail [email protected]
(Circulation. 2014;130:918-922.)
2014 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIRCULATIONAHA.113.004382

Downloaded from http://circ.ahajournals.org/

by guest on September 14, 2014
918

Silvain et al Coronary Revascularization in Diabetes 919

Table 1. Characteristics of Diabetic

Patients With CAD Compared With
Nondiabetic Patients
More frequent asymptomatic ischemic disease or
silent ischemia attributable to diabetic neuropathy
which appears early in the development of
diabetes
More severe coronary artery lesions that are
often multiple, with extensive and diffuse lesions
attributable to accelerated atherogenosis
Increased platelet reactivity and decrease platelet
inhibition in response to antiplatelet agents used
for primary or secondary prevention
More severe acute coronary syndrome with
higher risk of mortality after a myocardial
infarction, regardless of the treatment
Higher rate of in-stent restenosis and stent
thrombosis
More frequent comorbidities (renal insufficiency,
other localization of atherosclerotic disease),
leading to higher surgical risk when considering
surgical coronary revascularization.

coronary angiography, is more frequent

in diabetic patients than nondiabetic
patients and is associated with a worse
prognosis. The management of CAD
ranges from optimal medical therapy
(OMT) to coronary revascularization
with percutaneous coronary intervention (PCI) or coronary artery bypass
graft (CABG) surgery (Figure1).

Medical Therapy Versus

Revascularization
Asymptomatic patients without ischemia or with limited ischemia should be
treated with OMT only. However, there
is uncertainty on therapeutic strategy
when symptoms or moderate to severe
ischemia are present. Advancements
in both PCI and surgical techniques
have continued to improve the safety
and efficacy of coronary revascularization. However, results of randomized
studies comparing myocardial revascularization with OMT only have been
consistent in showing a lack of benefit
of revascularization to reduce mortality or myocardial infarction in diabetic
patients with stable CAD.
The Clinical Outcomes Utilizing
Revascularization and Aggressive
Drug Evaluation (COURAGE) trial
(n=2287) evaluated whether OMT
plus PCI was better than OMT alone
in patients with stable CAD who had
objective evidence of myocardial ischemia and significant obstructive coronary lesions.3,4 The primary end point
of death from any cause and nonfatal
myocardial infarction (MI) during a
median 4.6 years follow-up did not differ between the 2 treatment strategies,

Figure 1. Management of CAD in a diabetic patients. CAD indicates coronary artery

disease; NSTE-ACS, non-ST elevation-acute coronary syndrome; OMT, optimal medical
therapy; and QOL, quality of life.

nor did the rates of MI or stroke. The

766 diabetic patients enrolled in the
COURAGE trial had a higher rate of
primary end points than nondiabetic
patients (24.5% versus 16%), however
no difference was found between the 2
therapeutics strategies in this subgroup
of patients with rate of primary end
points of 24.5% with OMT alone versus 25% with OMT plus PCI (hazard
ratio, 0.99; 95% confidence interval,
0.731.32).3
The
Bypass
Angioplasty
Revascularization Investigation 2
Diabetes (BARI 2D) trial (n=2368)
evaluated whether PCI or CABG
(choice left to the discretion of the
treating physician) combined with
OMT would be better than OMT alone
in type 2 diabetic patients with stable
CAD and angiographically documented CAD.5 The primary end point
of all-cause mortality at 5 years followup did not differ between the 2 treatment strategies, nor did the rates of MI
or stroke. Taken together, COURAGE
and BARI-2D favor OMT alone in
stable CAD patients and particularly in
patients with diabetes mellitus.
However, these results need to be
interpreted with caution and should
be individualized, knowing that there
are limitations to these 2 trials. The
high crossover rates from OMT to
revascularization suggest that revascularization was just deferred in one
third of the patients randomized to a
conservative approach. Also, not all
of the subsets of patients with stable
CAD commonly encountered in clinical practice were represented in these
2 trials. So, the results may not be
applicable to all diabetic patients.
Documented ischemia was not mandatory for enrollment in either trial.
Therefore, many patients with severe
ischemia underwent revascularization
shortly after angiography, before they
could be enrolled in the trial. In contrast, patients without significant ischemia may have been randomized more
easily. Finally, the highest risk patients
with severe presentation, those with
complex CAD or left main artery disease or arrhythmic or hemodynamic

Downloaded from http://circ.ahajournals.org/ by guest on September 14, 2014

920CirculationSeptember 9, 2014

instability, were not enrolled in the

COURAGE or BARI 2D trials. Neither
were patients for whom revascularization was required for prompt control of
severe angina.
Neither OMT nor revascularization overrides the fact that diabetic
patients with CAD experience worse
outcomes compared with nondiabetic CAD patients. The only situation in which revascularization is not
debated is with a clinical presentation
of ST-elevation myocardial infarction
or non ST-elevation acute coronary
syndrome.

CABG or PCI
Revascularization
In the absence of multivessel disease
or a lesion involving the left main, PCI
is a simple and efficient technique to
revascularize 1 vessel. As soon as the
left main artery or 2 major epicardial
vessels are involved, especially the
LAD, discussion for the technique of
revascularization must occur. The benefit of off-pump CABG in diabetics is
still debated.6
The failure of PCI to show superiority over CABG in multivessel disease
was initially attributed to the use of

bare-metal stents, inadequate antiplatelet therapy to prevent stent thrombosis, and absence of optimal OMT for
secondary prevention. The Synergy
between PCI with Taxus and Cardiac
Surgery (SYNTAX) trial (n=1800)
comparing PCI with the first generation of drug (paclitaxel) eluting stent
(DES) with CABG for treating patients
with previously untreated 3-vessel or
left main coronary artery disease (or
both) concluded that CABG was the
best option for patients with 3-vessel
with or without associated left main
CAD.7 In the 452 diabetic patients of
the SYNTAX trial, the 1-year major
adverse cardiac and cerebrovascular
event rate was higher with PCI-DES
than with CABG, a difference driven
by an increase in repeat revascularization that reached 20.3% in diabetic PCI
patients versus 6.4% in diabetic CABG
patients (P<0.001). Moreover, mortality in diabetic patients was higher
in the PCI arm when compared with
CABG (13.5% versus 4.1%, P=0.04).8
In the more recently published
Future Revascularization Evaluation
in Patients with Diabetes Mellitus:
Optimal Management of Multivessel
Disease (FREEDOM) trial, 1900

diabetic patients with multivessel disease eligible for both revascularization

techniques were randomized to PCI
with DES (paclitaxel and sirolimus)
versus CABG.9 The primary end point
of all-cause mortality, nonfatal MI, or
stroke over a mean 3.8 years follow-up
favored CABG, with 18.7% of events at
5 years with CABG versus 26.6% with
PCI (P=0.005). All cause mortality was
lower with CABG at 5 years (10.3%
versus 16.3% P=0.049). Repeat revascularization (13% versus 5% P<0.001)
and nonfatal MI (13.9% versus 6.0%
P<0.001) were higher with PCI. PCI
had a lower rate of stroke (2.4% versus 5.2% P<0.001). These results from
SYNTAX and FREEDOM are compelling in favor of CABG for patients
with triple vessel disease (only 15%
had 2-vessel disease in FREEDOM).
The only subgroup of patients in
whom PCI seems to do equally well
with PCI, albeit with a higher rate of
repeat revascularization, is the group
with left main disease when isolated
or with 1-vessel disease.10 Data on
the best revascularization option for
left main disease should be provided
by the ongoing Evaluation of Xience
Prime versus Coronary Artery Bypass

Table 2. Selected Studies of Comparison of Revascularization Methods in Diabetic Patients

Patients
Year

Diabetic

Stents

LIMA, % Follow-Up

MACCE
(Including Repeat Revasc)

Mortality
PCI,%

CABG,%

P Value

PCI

CABG

P Value**

PCI With DES Versus CABG

Lee et al

Registry

2007

205

DES 100%

N/A

1 yr

Briguori et al13

Registry

2007

218

DES 100%

100%

1 yr

Hannan et al14

Registry

2008

6100

DES 100%

N/A

1.5 yr

6.9

8.5

Yang et al15

Registry

2008

352

DES 100%

99%

1 yr

3.8

3.8

CARDIA16

Specific RCT

2008

510

DES 71%

94%

1 yr

3.2

3.3

P=0.97

BARI 2D5

Indirect comparison

2009

953

DES 35%

81%

5 yr

10.8

13.6

N/A

SYNTAX7

Subgroup analysis RCT

2009

452

DES 100%

78%

5 yr

19.5

12.9

Specific RCT

2012

1900

DES 100%

N/A

5 yr

16.3

Registry

2013

5784

DES 100%

N/A

5 yr

32.5

12

FREEDOM9
Wu et al

17

10
5.9

P=0.6

27

12

P=0.006*

4.9

P=0.55

29

20.5

P=0.020*

P=0.75

10.5

10.7

P=0.49

18.3

4.9

P<0.001*

19.3

11.3

P=0.016*

23

22.4

N/A

P=0.065*

46.5

29.0

P<0.001*

10.9

P=0.049*

26.6

18.7

P=0.004*

23.5

P<0.001*

N/A

N/A

N/A

P=0.07

BARI-2D indicates Bypass Angioplasty Revascularization Investigation 2 Diabetes trial; CABG, coronary artery bypass graft; CARDIA, Coronary Artery Revascularization
in Diabetes trial; DES, drug-eluting stent; FREEDOM, Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease
trial; LIMA, left internal mammary artery; MACCE, major cardiovascular and cerebral events including repeat revascularization, with the exception of the registry of
Hannan et al, which only provided Death or myocardial infarction; PCI, percutaneous coronary intervention; RCT, randomized, controlled trial; and SYNTAX, Synergy
between PCI with Taxus and Cardiac Surgery trial.
*P<0.05.
After adjustment for propensity score for registries.

Downloaded from http://circ.ahajournals.org/ by guest on September 14, 2014

Silvain et al Coronary Revascularization in Diabetes 921

Disclosures

Figure 2. Choice of revascularization therapy in diabetic patients with CAD. CABG

indicates coronary artery bypass graft; CAD, coronary artery disease; LAD, left anterior
descending artery; and PCI, percutaneous coronary intervention.

Surgery for Effectiveness of Left Main

Revascularization (EXCEL)
trial
comparing CABG with PCI using the
Xience everolimus eluting stent in
2500 patients (NCT01205776).

What Type of
Revascularization?
Improvement in rates of repeat revascularization and lower rates of stent
thrombosis with DES have influenced
physicians choice in the type of revascularization for diabetic patients. This
is particularly true with the secondgeneration of DES using everolimus.11
PCI is also more attractive to patients
with its percutaneous approach, its
lower rate of stroke, and shorter length
of hospital stay. According to the results
of registries and randomized studies
comparing the 2 techniques (Table2)
and in the absence of contraindication
to surgery, PCI can be envisioned in
diabetic patients with single or 2-vessel
disease without complex lesions, when
the proximal LAD is not involved.18,19
Patients presenting with ST-elevation
myocardial infarction should undergo
primary PCI of the culprit lesion only
and then be reconsidered once stabilized for CABG if there is multivessel
disease involving the LAD. For non
ST-elevation acute coronary syndrome,
the choice is more difficult. These
patients can be considered like stable
CAD patients in terms of revascularization. Based on the recent results of
the FAME-2 trial supporting the use

of FFR measurement in stable CAD,20

FFR-guided PCI should be used more
thoroughly to evaluate lesions in diabetic patients who are identified with
multivessel disease.

How to Choose?
In low-risk stable CAD patients, the
strategy of initial OMT is safe and
should be the default approach. The
choice can be PCI in diabetic patients
with single or 2-vessel disease without
involvement of the LAD. Discussion
of the patients case with a multidisciplinary heart team should be considered to weigh the benefit and risk of
PCI versus CABG (Figure2).

Case Resolution
The patient was diagnosed with type
2 diabetes mellitus and CAD with
multivessel disease. Although asymptomatic, the results of the stress test
with possible life-threatening ventricular tachycardia made us consider
the patient suitable for revascularization, and CABG was chosen as a first
choice by the staff and accepted by the
patients after explanation. He underwent revascularization with CABG
using bilateral mammary artery grafts
with an excellent immediate result and
discharge without complications.

Sources of Funding
Manuscript supported by the ACTION
academic study group for cardiovascular
research, www.action-coeur.org.

Dr Silvain reports receiving research

grants to the institution from BoehringerIngelheim, Daiichi-Sankyo, Eli Lilly,
BRAHMS and Sanofi-Aventis, Fdration
Franaise de Cardiologie and Socit
Franaise de Cardiologie, INSERM; consultant fees from Daiichi-Sankyo, Eli Lilly;
AstraZeneca, and the Medicines Company;
and lecture fees from AstraZeneca,
Cordis, Daiichi-Sankyo, Eli Lilly, Iroko
Cardio, and STENTYS. Dr Vignalou has
received research grants from Servier. Dr
Kerneis has received research grants from
Fdration Francaise de Cardiologie. Pr
Collet has received research grants from
Bristol-Myers Squibb, Sanofi-Aventis,
Eli Lilly, Guerbet Medical, Medtronic,
Boston Scientific, Cordis, Stago, Centocor,
Fondation de France, INSERM, Fdration
Franaise de Cardiologie, and Socit
Franaise de Cardiologie; consulting fees
from Sanofi-Aventis, Eli Lilly, and BristolMyers Squibb; and lecture fees from BristolMyersSquibb, Sanofi-Aventis, and Eli Lilly.
Prof. Montalescot reports receiving consulting fees from Bayer, Boehringer-Ingelheim,
CFR, Europa, GlaxoSmithKline, GLG,
Iroko Cardio International, Lead-Up, LLC,
Luminex, McKinsey, Remedica, Servier,
TIMI Group, WebMD, and Wolters; consulting fees and grant support from BristolMyers Squibb, AstraZeneca, Biotronik,
Eli Lilly, The Medicines Company,
Medtronic, Menarini, Sanofi-Aventis,
Pfizer, and Accumetrics; and grant support
from Abbott Vascular, Daiichi-Sankyo,
Nanospheres, and Stentys. Dr Barthlmy
reports no conflicts.

References
1. Association AD. Http://www.Diabetes.Org/
diabetes-basics/diabetes-statistics/. Diabetes
Statistics. Accessed May 22, 2013.
2. Hess K, Marx N, Lehrke M. Cardiovascular
disease and diabetes: The vulnerable
patient. Eur Heart J Suppl 2012;14 (suppl
B):B4B13.
3. Boden WE, ORourke RA, Teo KK, Hartigan
PM, Maron DJ, Kostuk WJ, Knudtson M,
Dada M, Casperson P, Harris CL, Chaitman
BR, Shaw L, Gosselin G, Nawaz S, Title
LM, Gau G, Blaustein AS, Booth DC, Bates
ER, Spertus JA, Berman DS, Mancini GB,
Weintraub WS; COURAGE Trial Research
Group. Optimal medical therapy with or
without PCI for stable coronary disease. N
Engl J Med. 2007;356:15031516.
4. Weintraub WS, Diamond GA. Predicting
cardiovascular events with coronary calcium
scoring. N Engl J Med. 2008;358:13941396.
5. Frye RL, August P, Brooks MM, Hardison
RM, Kelsey SF, MacGregor JM, Orchard
TJ, Chaitman BR, Genuth SM, Goldberg
SH, Hlatky MA, Jones TL, Molitch ME,
Nesto RW, Sako EY, Sobel BE. A randomized trial of therapies for type 2 diabetes

Downloaded from http://circ.ahajournals.org/ by guest on September 14, 2014

922CirculationSeptember 9, 2014

and coronary artery disease. N Engl J Med.

2009;360:25032515.
6. Srinivasan AK, Grayson AD, Fabri BM.
On-pump versus off-pump coronary artery
bypass grafting in diabetic patients: a propensity score analysis. Ann Thorac Surg.
2004;78:16041609.
7. Serruys PW, Morice MC, Kappetein AP,
Colombo A, Holmes DR, Mack MJ, Sthle
E, Feldman TE, van den Brand M, Bass EJ,
Van Dyck N, Leadley K, Dawkins KD, Mohr
FW; SYNTAX Investigators. Percutaneous
coronary intervention versus coronary-artery
bypass grafting for severe coronary artery
disease. N Engl J Med. 2009;360:961972.
8. Kappetein AP, Head SJ, Morice MC, Banning
AP, Serruys PW, Mohr FW, Dawkins
KD, Mack MJ; SYNTAX Investigators.
Treatment of complex coronary artery disease in patients with diabetes: 5-year results
comparing outcomes of bypass surgery and
percutaneous coronary intervention in the
SYNTAX trial. Eur J Cardiothorac Surg.
2013;43:10061013.
9. 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; FREEDOM
Trial Investigators. Strategies for multivessel
revascularization in patients with diabetes. N
Engl J Med. 2012;367:23752384.
10. Morice MC, Serruys PW, Kappetein AP,

Feldman TE, Sthle E, Colombo A, Mack
MJ, Holmes DR, Torracca L, van Es GA,
Leadley K, Dawkins KD, Mohr F. Outcomes
in patients with de novo left main disease
treated with either percutaneous coronary
intervention using paclitaxel-eluting stents
or coronary artery bypass graft treatment in
the Synergy Between Percutaneous Coronary

Intervention with TAXUS and Cardiac

Surgery (SYNTAX) trial. Circulation.
2010;121:26452653.
11. Sabate M, Cequier A, Iiguez A, Serra A,
Hernandez-Antolin R, Mainar V, Valgimigli
M, Tespili M, den Heijer P, Bethencourt A,
Vazquez N, Gmez-Hospital JA, Baz JA,
Martin-Yuste V, van Geuns RJ, Alfonso F,
Bordes P, Tebaldi M, Masotti M, Silvestro
A, Backx B, Brugaletta S, van Es GA,
Serruys PW. Everolimus-eluting stent versus bare-metal stent in ST-segment elevation
myocardial infarction (EXAMINATION): 1
year results of a randomised controlled trial.
Lancet. 2012;380:14821490.
12. Lee MS, Jamal F, Kedia G, Chang G, Kapoor
N, Forrester J, Czer L, Zimmer R, DeRobertis
M, Trento A, Makkar RR. Comparison of
bypass surgery with drug-eluting stents for
diabetic patients with multivessel disease. Int
J Cardiol. 2007;123:3442.
13. Briguori C, Condorelli G, Airoldi F, Focaccio
A, DAndrea D, Cannavale M, Abarghouei
AA, Giordano S, De Vivo F, Ricciardelli B,
Colombo A. Comparison of coronary drugeluting stents versus coronary artery bypass
grafting in patients with diabetes mellitus.
Am J Cardiol. 2007;99:779784.
14. Hannan EL, Wu C, Walford G, Culliford AT,
Gold JP, Smith CR, Higgins RS, Carlson RE,
Jones RH. Drug-eluting stents vs. coronaryartery bypass grafting in multivessel coronary
disease. N Engl J Med. 2008;358:331341.
15. Yang JH, Gwon HC, Cho SJ, Hahn JY,

Choi JH, Choi SH, Lee YT, Lee SH, Hong
KP, Park JE. Comparison of coronary artery
bypass grafting with drug-eluting stent
implantation for the treatment of multivessel
coronary artery disease. Ann Thorac Surg.
2008;85:6570.
16. Daemen J, Kuck KH, Macaya C, LeGrand
V, Vrolix M, Carrie D, Sheiban I, Suttorp
MJ, Vranckx P, Rademaker T, Goedhart D,
Schuijer M, Wittebols K, Macours N, Stoll

HP, Serruys PW; ARTS-II Investigators.

Multivessel coronary revascularization in
patients with and without diabetes mellitus:
3-year follow-up of the ARTS-II (Arterial
Revascularization Therapies Study-Part II)
trial. J Am Coll Cardiol. 2008;52:19571967.
17. Wu C, Camacho FT, Zhao S, Wechsler AS,
Culliford AT, Lahey SJ, King SB 3rd, Walford
G, Gold JP, Smith CR, Jordan D, Higgins RS,
Hannan EL. Long-term mortality of coronary artery bypass graft surgery and stenting
with drug-eluting stents. Ann Thorac Surg.
2013;95:12971305.
18. Reeves BC, Angelini GD, Bryan AJ, Taylor
FC, Cripps T, Spyt TJ, Samani NJ, Roberts
JA, Jacklin P, Seehra HK, Culliford LA,
Keenan DJ, Rowlands DJ, Clarke B,
Stanbridge R, Foale R. A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus
percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of
the left anterior descending coronary artery.
Health Technol Assess. 2004;8:143.
19. Jaffery Z, Kowalski M, Weaver WD, Khanal
S. A meta-analysis of randomized control
trials comparing minimally invasive direct
coronary bypass grafting versus percutaneous coronary intervention for stenosis of the
proximal left anterior descending artery. Eur
J Cardiothorac Surg. 2007;31:691697.
20. De Bruyne B, Pijls NH, Kalesan B, Barbato
E, Tonino PA, Piroth Z, Jagic N, MbiusWinkler S, Mobius-Winckler S, Rioufol G,
Witt N, Kala P, MacCarthy P, Engstrm T,
Oldroyd KG, Mavromatis K, Manoharan
G, Verlee P, Frobert O, Curzen N, Johnson
JB, Jni P, Fearon WF; FAME 2 Trial
Investigators. Fractional flow reserveguided PCI versus medical therapy in
stable coronary disease. N Engl J Med.
2012;367:9911001.

Downloaded from http://circ.ahajournals.org/ by guest on September 14, 2014