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Pr Valentin Fuster: diabetes and multivessel coronary disease

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Hello! You’re on MD-FM INSIGHT, the first web radio for e-Continuing Medical Education.

Today we’re pleased to offer you a "Question & Answer" program devoted to the management of multivessel coronary aertery disease.


Last November, at the 2012 meeting of the American Heart Association, the results of the FREEDOM trial were presented, comparing CABG and PCI in such patients.


We interviewed the principal investigator of the study, Dr. Valentin Fuster, from Mount Sinai in New York.

Dr. Fuster, first of all, maybe tell us a bit about the design of this study…

Furster: So we studied 2000 patients that were randomized into the use of intervention with drug eluting stents and coronary artery bypass grafting. This study involved 131 medical centres across the world. This is the first prospective larger study on diabetes with multi-vessel disease that were very aggressively treated with medical therapy. The primary endpoint of this study, in terms of objectives, was the combination of myocardial infarction, stroke and death of all causes –any of these events as a first event counted.



And so we are quite excited to know, what did you find?


Fuster: The results were very significant. What we found is that at 5 year follow up: about 26% of patients undergoing PCI with drug eluting stents had an event, while 18% in the group that was treated with CABG. That’s a relative difference of about 35-36%. In terms of myocardial infarction and in terms of all cause mortality, independently, the results were also significant, favouring bypass surgery. The rate of stroke was slightly higher, however, in bypass surgery than in PCI, but the numbers were small and didn’t affect the overall results. Perhaps one of the most striking data that came out is that any subgroup --men vs. women, race, black vs. white, countries, SYNTAX score, which is so important -- it didn’t make a difference, in all these subgroups: CABG was superior and with each of the variables of the subgroups. So the results were so clear that, in a way, I think this is going to change practice.



So this was quite a unique patient population… so what about for less complex patient groups, how do these results apply to them?


Fuster: They don’t apply, but these do apply to 20 to 25% of patients in our practice who undergo intervention procedures. On the other hand, I think the SYNTAX study showed that for patients without diabetes and patients with multi-vessel disease, also surgical intervention was actually superior to the use of stenting. I think that what we are learning is a little bit the resuscitation of bypass surgery I would say. Maybe the pendulum went too far into complex disease and now we are beginning to find that perhaps we have to be much more cautious. 



What about economic implications there?


Fuster: This has already been presented at this meeting and in the long term, again, CABG is superior to PCI in term of cost effectiveness so really it’s a winner in all accounts.



So it’s looking quite clean cut at this stage. So what is the take home bottom line message for clinicians in practice right now?


Fuster: The take home message, I can give you an example: 40% of patients declined to enter into the study because they preferred PCI, because you don’t open the chest. I think today we have to be much more cautious and try to convince this group to undergo bypass surgery. I think this is actually the message.”



Is this enough to say that CABG should actually be the first choice?


Fuster: I believe so



Despite the slight increase in stroke in the CABG group?


Fuster: Well I mean this was about 5%, in PCI it was 2%. What is interesting is these strokes with CABG don’t happen at the time of the procedure, they may happen a little bit later. So I think it’ hard to say how we can prevent them, although the numbers are relatively small.



This show is over. By visiting the MD-FM website, you can check out the themes of the programs we will be offering you regularly.

See you soon on MD-FM.


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