Coronary Artery Bypass Surgery

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The only randomized trial that has compared CABG with PCI in patients with ACS was the AWESOME trial.97 This study compared the two revascularization strategies in patients who had medically refractory unstable angina and were at high risk for adverse outcomes with CABG. Among 2431 patients identified, 454 were considered acceptable for both PCI and CABG; 1650 patients were not deemed to be candidate for both therapies and entered a physician-directed registry, and the 327 who were considered candidates for both treatment but refused randomization entered a patient-choice registry. Overall, diabetes prevalence was 31%. The respective CABG and PCI 3-year survival rates for diabetic patients were 72% and 81% for those randomized, 85% and 89% for those in the patient-choice registry, and 73% and 71% for those in the physician-directed registry.97 None of these differences was statistically significant. These results must be interpreted with caution because, from both a surgical perspective (left IMA used in 70% of cases) and an interventional perspective (stents and GP IIb/IIIa antagonists used in 54% and 11% of patients respectively), the way patients were revascularized may not comply with current standards. Nevertheless, CABG and PCI appear to be comparable options for high-risk diabetic patients with ACS, and the choice of revascu-larization should be made individually based on coronary anatomy, ventricular function, age, and comorbidities.

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