Vol 20, No 4 (2013)
Review Article
Published online: 2013-07-26

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Optimal revascularization in diabetes after the FREEDOM trial: Were the controversies finally settled?

Alexander Tenenbaum, Enrique Fisman
DOI: 10.5603/CJ.2013.0090
Cardiol J 2013;20(4):331-336.


The prevalence of diabetes mellitus (DM) is growing worldwide. Prothrombotic and proinfl ammatory
states, in adjunct to endothelial dysfunction and metabolic disorders, such as hyperglycemia,
dyslipidemia, obesity, insulin resistance, and oxidative stress, are key features of the
accelerated atherosclerotic progression observed in patients with DM. Moreover, drug-eluting
stents (DES) thrombosis rate was higher in DM than in non-DM patients and DM itself was
identifi ed as an independent predictor of stent thrombosis, particularly due to the impaired
response to dual antiplatelet therapy. The accumulating data even before the FREEDOM trial
provided strong evidence that in patients with DM and complex coronary artery disease, coronary
artery bypass grafting (CABG) was superior to percutaneous coronary intervention (PCI)
which was based on the fi rst-generation DES. The FREEDOM trial enrolled 1900 patients
with DM and multivessel coronary artery disease treated with CABG surgery or PCI with the
fi rst-generation DES. The patients were followed for a median 3.8 years; CABG was superior
to PCI as it signifi cantly reduced rates of death and myocardial infarction (MI), with a higher
rate of stroke. The benefi t of CABG was driven by differences in rates of both MI (p < 0.001)
and death from any cause (p = 0.049). Following the FREEDOM results, patients with DM
ought to be informed before coronary angiography about the potential survival benefi t from
CABG for the treatment of a complex disease. However, it should be noticed that the second generation
DES were associated with better outcomes compared to the fi rst-generation DES. New
stent designs are continually being developed, with the aim of further improving the clinical
effi cacy and the safety profi le of these devices. Therefore, although the results of the FREEDOM
trial clearly demonstrated that CABG was superior to PCI in DM, a comparative analysis of
the new incoming stents warrants further investigation.