Saturday, September 19, 2015

CABG Skyrockets Among Diabetics; Lessons for Heart Surgeons Diabetics: Worse Outcomes After CABG

The proportion of diabetics who underwent coronary artery bypass grafting (CABG) jumped almost fivefold over the past 40 years, according to a recent single-center study covering over 57,000 patients at the Cleveland Clinic.
And although surgical outcomes have improved substantially, this combination of diabetes and heart bypass has become an excessively costly healthcare burden, as the results also show that diabetics have more postoperative complications and worse survival than nondiabetics, contributing to ballooning healthcare costs.
Diabetes is both a marker for high-risk, resource-intensive, and expensive care after CABG, and an independent risk factor for reduced long-term surviva.Moreover, heart disease represents the major cause of death in diabetes.

While endocrinologists may be the physicians bearing the greatest responsibility for managing patients with diabetes, the disease is also having a tremendous impact on surgery, this new analysis shows, which included 10,362 patients with diabetes and 45,139 patients without the disease who underwent first-time CABG between January 1972 and January 2011.
Results showed that the proportion of diabetics who underwent CABG jumped from 7% in the 1970s to 37% in the 2000s.
Diabetics also had worse outcomes after coronary bypass compared with nondiabetics: more in-hospital deaths (2.0% vs 1.3%), more deep sternal wound infections (2.3% vs 1.2%), more strokes (2.2% vs 1.4%), more renal failure (4.0% vs 1.3%), and longer hospital stays (9.6% vs 6.0%), (P<.05 for all). Diabetics also spent more hours in the intensive care unit than nondiabetics.Eleven percent of nondiabetic patients and 7.5% of diabetic patients received bilateral internal thoracic artery (ITA) grafts.

After propensity matching, 5-year survival was 80% in diabetics vs 84% in nondiabetics. But at 10 years, survival was 56% in diabetics vs 66% in nondiabetics. And at 20 years, it was 20% in diabetics vs 32% in nondiabetics.
After matching, diabetics still had longer hospital stays, as well as higher incidences of sternal wound infection and stroke, although cost differences between diabetics and nondiabetics were no longer significant.
"The use of skeletonized bilateral internal thoracic arteries in young, nonobese diabetic patients with a greater-than-10-year life expectancy is a reasonable risk to take," they assert.
"Perhaps in an elderly, morbidly obese female diabetic patient at high risk for sternal infection and shorter life expectancy, a single left internal thoracic artery would be best."
Other options to improve long-term survival after CABG in diabetic patients include using radial artery grafts and delaying elective procedures until glycemic control improves, they add.
Another expert, Paul Kurlansky, MD, assistant professor of surgery at Columbia University College of Physicians and Surgeons in New York, says arterial conduits may be the "optimal form of coronary revascularization [in diabetic patients]," in a third linked editorial, published in the August issue.
"Arterial conduits have greater long-term patency. The internal mammary artery [IMA], in particular, may be beneficial to the downstream vascular endothelium through the active secretion of nitric oxide," he commented.
"Although many surgeons have been reluctant to use the internal mammary artery in diabetic patients…several studies have documented that using a skeletonized approach to bilateral IMA grafting can be performed in diabetics without an increase in sternal wound infection, but with an improved long-term survival," he observes (Circulation. 2012;126:2935-2942).
Some evidence also supports using one IMA and one radial artery in diabetic patients, Dr Kurlansky continues.
"Given the incredibly low rate of bilateral IMA grafting in the United States — less than 5% in general, even less for diabetics — the surgical community is obligated to meet the rising challenge of the diabetic patient with the optimal therapeutic approach, which clearly supports arterial grafting," he emphasizes.
In the meantime, cardiac surgeons can play an important role in extending the lives of patients with diabetes by optimizing coronary revascularization, performing bilateral internal thoracic artery grafting with complete revascularization whenever feasible.

Reference :
J Thorac Cardiovasc Surg. 2015;150:304-312, 313–314, 284–285, and published online July 16, 2015.

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