Regulate LDL-C level for those undergoing coronary revascularization (Diabetic Patients)

Improve prognosis in patients with type 2 diabetes mellitus
Regulate low-density lipoprotein cholesterol level for those undergoing coronary revascularisation

Main Takeaway

• Depending on the revascularisation strategy, LDL-C levels yield a differential influence on cardiovascular (CV) outcomes
  • Compared to patients with 1-year LDL-C <70 mg/dl, patients who had 1-year LDL-C ≥100 mg/dl showed a significant increase in long-term cardiovascular risk
  • Patients randomised to coronary artery bypass grafting (CABG) group had lower rates of major adverse cardiac or cerebrovascular events (MACCE) versus the optimal medical therapy (OMT) alone group

Why This Matters

• Guideline-directed management of patients with coronary heart disease (CHD) and type 2 diabetes mellitus (T2DM) includes intensive lifestyle intervention along with aggressive secondary prevention (OMT) and an appropriate revascularisation strategy
  • This analysis highlights the significance of LDL-C control in the first year post-procedure

Study Design

• Pooled analysis: combined individual patient-level information from 3 federally funded trials (BARI 2D, Courage, and Freedom)
• 4,050 patients with T2DM (mean age = 62.8 ± 8.8 years; female = 27.0%; median follow-up = 3.9 years [after the index 1-year assessment]) were categorised according to LDL-C levels at 1 year following randomisation
  • Key inclusion criteria: all patients with CHD and T2DM from BARI-2D and Freedom trials and only patients with T2DM in the Courage trial
  • Key exclusion criteria: patients with LDL-C <20 mg/dl and triglycerides >400 mg/dl both at baseline and 1 year
  • Primary outcome: 4-year rate of the MACCE composite (all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke)
  • Secondary outcomes: subsequent revascularisation

Key Results

• Patients with 1-year LDL-C levels ≥100 mg/dl experienced higher 4-year cumulative risk of MACCE
  • 17.2% versus 13.3% (70 to <100 mg/dl) versus 13.1% (<70 mg/dl); p = 0.016
• Incidence of CV events following a coronary revascularisation procedure or OMT:
  • When comparing CABG with PCI, CABG led to significantly lower rates of MACCE for those with 1-year LDL-C levels:
    • Between 70 and <100 mg/dl: HR: 0.49; 95% CI, 0.31 to 0.79; p = 0.003
    • ≥100 mg/dl: HR: 0.53; 95% CI, 0.30 to 0.91; p = 0.022
  • When compared with both OMT and PCI patients, CABG correlated with lower rates of subsequent revascularisation in all 1-year LDL-C strata
    • No difference in subsequent revascularisation rates were observed when comparing PCI with OMT in any of the 1-year LDL-C strata

Limitations

• There may be a possibility of additional confounders influencing the association between cardiovascular outcomes and both the choice of revascularisation procedure and the LDL-C control rate
• There is a lack of data for adherence to the prescribed therapy
• A systematic analysis was not pursued for lipid lowering therapy during the first year of follow-up
• There could be an occurrence of immortal time bias