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Quality of Life After PCI vs CABG Among Patients With Diabetes and Multivessel Coronary Artery Disease: A Randomized Clinical Trial
Open accessAbstract
IMPORTANCE: The FREEDOM trial demonstrated that among patients with diabetes mellitus and multivessel coronary artery disease, coronary artery bypass graft (CABG) surgery resulted in lower rates of death and myocardial infarction but a higher risk of stroke when compared with percutaneous coronary intervention (PCI) using drug-eluting stents. Whether there are treatment differences in health status, as assessed from the patient's perspective, is unknown. OBJECTIVES: To compare the relative effects of CABG vs PCI using drug-eluting stents on health status among patients with diabetes mellitus and multivessel coronary artery disease. DESIGN, SETTING, AND PARTICIPANTS: Between 2005 and 2010, 1900 patients from 18 countries with diabetes mellitus and multivessel coronary artery disease were randomized to undergo either CABG surgery (n = 947) or PCI (n = 953) as an initial treatment strategy. Of these, a total of 1880 patients had baseline health status assessed (935 CABG, 945 PCI) and comprised the primary analytic sample. INTERVENTIONS: Initial revascularization with CABG surgery or PCI. MAIN OUTCOMES AND MEASURES: Health status was assessed using the angina frequency, physical limitations, and quality-of-life domains of the Seattle Angina Questionnaire at baseline, at 1, 6, and 12 months, and annually thereafter. For each scale, scores range from 0 to 100 with higher scores representing better health. The effect of CABG surgery vs PCI was evaluated using longitudinal mixed-effect models. RESULTS: At baseline, mean (SD) scores for the angina frequency, physical limitations, and quality-of-life subscales of the Seattle Angina Questionnaire were 70.9 (25.1), 67.3 (24.4), and 47.8 (25.0) for the CABG group and 71.4 (24.7), 69.9 (23.2), and 49.2 (25.7) for the PCI group, respectively. At 2-year follow-up, mean (SD) scores were 96.0 (11.9), 87.8 (18.7), and 82.2 (18.9) after CABG and 94.7 (14.3), 86.0 (19.3), and 80.4 (19.6) after PCI, with significantly greater benefit of CABG on each domain (mean treatment benefit, 1.3 [95% CI, 0.3-2.2], 4.4 [95% CI, 2.7-6.1], and 2.2 [95% CI, 0.7-3.8] points, respectively; P < .01 for each comparison). Beyond 2 years, the 2 revascularization strategies provided generally similar patient-reported outcomes. CONCLUSIONS AND RELEVANCE: For patients with diabetes and multivessel CAD, CABG surgery provided slightly better intermediate-term health status and quality of life than PCI using drug-eluting stents. The magnitude of benefit was small, without consistent differences beyond 2 years, in part due to the higher rate of repeat revascularization with PCI. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00086450.
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“There was also a small favorable benefit in quality of life favoring CABG from 6 months to 2 years, although there was no further accrual of benefit beyond 2 years.294”
From Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: a scientific statement from the American Heart Association (2020) · cites this paper as [294]
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“QoL substudy evaluated the health status of patients enrolled in the FREEDOM cohort at baseline, 1, 6 and 12 months and annually thereafter by means of the Seattle Angina Questionnaire (SAQ) and the Rose Dyspnea Scale (RDS).(29) The SAQ is a validated QoL measurement tool designed to evaluate CAD-related health status…”
MethodYang, L.-X., Zhou, Y.-J., Wang, Z.-J., Li, Y.-P., & Chai, M. (2014) · Journal of Geriatric Cardiology · doi:10.11909/j.issn.1671-5411.2014.03.003 · Cited by 12
External Validation of the FREEDOM Score for Individualized Decision Making Between CABG and PCI.
Takahashi, K., Serruys, P., Fuster, V., Farkouh, M., Spertus, J., Cohen, D., Park, S.-J., Park, D.-W., Ahn, J.-M., Onuma, Y., et al. (2022) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2022.01.049 · Cited by 11
Ferket, B., Thourani, V., Voisine, P., Hohmann, S., Chang, H. L., Smith, P. K., Michler, R., Ailawadi, G., Perrault, L., Miller, M. A., et al. (2019) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2019.06.040 · Cited by 11
Stenvall, H., Tierala, I., Räsänen, P., Laine, M., Sintonen, H., & Roine, R. (2017) · European Heart Journal - Quality of Care and Clinical Outcomes · doi:10.1093/ehjqcco/qcw024 · Cited by 11
Singh, S., Sinha, V., Singh, S., Kapoor, L., Praharaj, S., Tikka, S., & Singh, L. (2020) · The Indian journal of medical research · doi:10.4103/ijmr.ijmr_1310_18 · Cited by 9
Won, M. H. (2019) · Korean Journal of Adult Nursing · doi:10.7475/kjan.2019.31.6.691 · Cited by 10
“이는 관상동맥질환자의 건강 관련 삶의 질은 연령, 성별 및 질병중증도와 같은 개인적 특성에 영 향을 받는다고 보고한 선행연구[6,11,12]와 퇴원 후 시간의 경”
Diabetes and multivessel disease
Godoy, L. C., Rao, V. A., & Farkouh, M. E. (2018) · Current Opinion in Cardiology · doi:10.1097/hco.0000000000000550 · Cited by 10
McGrath, B., Norris, C., Hardwicke-Brown, E., Welsh, R., & Bainey, K. (2017) · European Heart Journal - Quality of Care and Clinical Outcomes · doi:10.1093/ehjqcco/qcw055 · Cited by 9
Mahdavi, M., Abbasi, I., & Mohammadi, N. (2015) · doi:10.18869/acadpub.hms.21.2.67 · Cited by 9
Nonsternotomy multivessel coronary artery bypass grafting: A key development in cardiac surgery
Ruel, M. (2021) · JTCVS Techniques · doi:10.1016/j.xjtc.2021.09.033 · Cited by 8
Residual angina in female patients after coronary revascularization.
Vogel, B., Goel, R., Kunadian, V., Kalkman, D., Chieffo, A., Appelman, Y., & Mehran, R. (2019) · International Journal of Cardiology · doi:10.1016/j.ijcard.2019.01.043 · Cited by 8
On-Pump Coronary Artery Bypass Graft: The State of the Art.
Cuminetti, G., Bonadei, I., Vizzardi, E., Sciatti, E., & Lorusso, R. (2019) · Reviews on recent clinical trials · doi:10.2174/1574887114666190301142114 · Cited by 8
Castelvecchio, S., Menicanti, L., Garatti, A., Tramarin, R., Volpe, M., & Parolari, A. (2016) · Annals of Thoracic Surgery · doi:10.1016/j.athoracsur.2016.02.081 · Cited by 8
Hybrid approach for coronary artery revascularization: where do we stand?
Toeg, H., Al-Atassi, T., Labinaz, M., May, M. L. L., & Ruel, M. (2014) · Current Opinion in Cardiology · doi:10.1097/hco.0000000000000112 · Cited by 8
“Recent findings Current forms of HCAR include off-pump mini-sternotomy or on-pump full sternotomy CABG [left internal mammary artery (LIMA)-to-left anterior descending artery(LAD) CABG followed by drug-eluting stents (DES) to non-LAD territories], robotic-assisted off-pump HCAR (robotic LIMA-to-LAD CABG and DES to non…”
BackgroundMethodInfluentialCoronary Microvascular Dysfunction
Carli, M. F. D. (2025) · Heart Failure Clinics · doi:10.1016/j.hfc.2025.01.002 · Cited by 7
Rahman, A., Haider, R., Shirin, H., Sobhan, A., & Huq, K. E. (2024) · Cureus · doi:10.7759/cureus.52645 · Cited by 7
“A study by Abdallah et al. observed that patients who underwent CABG had better QoL between six months and two years compared to those who underwent PCI; however, these differences were not found significant [17].”
ResultFan, Q., Liu, J., Xu, Y., Ni, R., Xi, R., Wang, F., Hu, J., Sun, H.-Y., Yang, Z.-K., Zhou, M., et al. (2021) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2021.675722 · Cited by 7
Kok, M. M., & von Birgelen, C. (2020) · EuroIntervention · doi:10.4244/eijv15i14a221 · Cited by 8
Bruckel, J., Wagle, N. W., O’Brien, C., Elias, J. S., McKenna, S., Meyers, P. M., Fifer, M. A., Pomerantsev, E. V., & Yeh, R. W. (2015) · Critical Pathways in Cardiology A Journal of Evidence-Based Medicine · doi:10.1097/hpc.0000000000000058 · Cited by 9
Krause, T. T., Afzal, S., Gjata, A., Lindner, M., Saad, L., Steinbach, M., Zayat, R., Haneya, A., Werner, N., & Leick, J. (2024) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2024.1451229 · Cited by 6
Effects of percutaneous coronary intervention on dyspnea in stable coronary artery disease
Wester, M., Koll, F., Luedde, M., Langer, C., Resch, M., Luchner, A., Müller, K., Zeman, F., Koller, M., Maier, L., et al. (2022) · Clinical Research in Cardiology · doi:10.1007/s00392-022-02107-x · Cited by 6
Ono, M., Serruys, P., Kawashima, H., Lunardi, M., Wang, R.-T., Hara, H., Gao, C., Garg, S., O'Leary, N., Wykrzykowska, J., et al. (2022) · European Heart Journal - Quality of Care and Clinical Outcomes · doi:10.1093/ehjqcco/qcac052 · Cited by 6
Dawson, L. P., Quinn, S. J., Tong, D., Boyle, A. J., Hamilton-Craig, C. R., Adams, H. S. L., & Layland, J. J. (2022) · Cardiovascular revascularization medicine · doi:10.1016/j.carrev.2022.06.017 · Cited by 7
Gao, K., Li, B.-L., Zhang, M., Rong, J., Yang, L., Fan, L., Liang, Q., Wu, W., Feng, Z., Yang, W.-W., et al. (2021) · Angiology · doi:10.1177/0003319721998575 · Cited by 6
“The SAQ, which quantifies 5 domains to measure the impact of angina on patient health status, has been shown to be effective, reproducible, and sensitive to changes in clinical symptoms.(34,35) Safley et al reported that all SAQ scores improved in patients with CTO and non-CTO patients after PCI, and there were no dif…”
MethodLong-term survival in patients who had CABG with or without prior coronary artery stenting
Rai, P., Taylor, R., & Bittar, M. N. (2020) · Open Heart · doi:10.1136/openhrt-2019-001160 · Cited by 6
Ruel, M., Sun, L. Y., & Gaudino, M. (2020) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2019.04.088 · Cited by 6
Kumar, R., Hote, M., Sharma, G., Thakur, B., & Airan, B. (2017) · doi:10.11648/j.ijcts.20170305.14 · Cited by 6
“In 1954, Murray and colleagues were considering a direct surgical approach to CAD and reported experimental studies of anastomosing the ITA to a coronary artery.”
BackgroundInfluentialLawton, R., Seed, P. T., Kordowicz, M., Schofield, P., Tylee, A., & Ashworth, M. (2014) · The British journal of general practice : the journal of the Royal College of General Practitioners · doi:10.3399/bjgp14x680137 · Cited by 6
Operative Techniques in Coronary Artery Bypass Surgery: An Illustrated Guide to Personalized Therapy
Albert, A., Assmann, A., Assmann, A., Aubin, H., & Lichtenberg, A. (2021) · doi:10.1007/978-3-030-48497-2 · Cited by 6
“Totally arterial revascularization with BITA can be conducted in aortic no-touch technique to revascularize all possible targets on the anterior, lateral and posterior walls, as far as the RITA is long enough [45].”
MethodInfluence of Pullback Pressure Gradient on Residual Angina at One Year
Mizukami, T., Ikeda, K., Munhoz, D., Sakai, K., Sonck, J., Matsuo, H., Shinke, T., Ando, H., Ko, B., Biscaglia, S., et al. (2026) · Circulation. Cardiovascular Interventions · doi:10.1161/circinterventions.125.015851 · Cited by 5
Minimally Invasive CABG Is The Future: Pro.
Ruel, M., & Halkos, M. E. (2024) · Seminars in Thoracic and Cardiovascular Surgery · doi:10.1053/j.semtcvs.2024.09.003 · Cited by 5
Quality of Life After Fractional Flow Reserve–Guided PCI Compared With Coronary Bypass Surgery
Fearon, W., Zimmermann, F., Ding, V., Zelis, J., Piróth, Z., Davidavičius, G., Mansour, S., Kharbanda, R., Östlund-Papadogeorgos, N., Oldroyd, K., et al. (2022) · Circulation · doi:10.1161/circulationaha.122.060049 · Cited by 5
Nielsen, S. N., Rasmussen, T. B., Lassen, J., Berg, S., Thrysoee, L., Møller, J., Jensen, L., Thuesen, A. L., Christensen, A. V., Ekholm, O., et al. (2020) · Quality of Life Research · doi:10.1007/s11136-020-02573-8 · Cited by 5
Zheng, X., Dreyer, R., Curtis, J., Liu, S.-L., Xu, X., Bai, X., Li, X., Zhang, H.-B., Wang, S.-M., Masoudi, F., et al. (2020) · Journal of the American Heart Association : Cardiovascular and Cerebrovascular Disease · doi:10.1161/jaha.119.014421 · Cited by 5
Grundeken, M., White, R. M., Hernandez, J., Dudek, D., Cequier, Á., Haude, M., van Boven, A. J., Piek, J., Helqvist, S., Sabaté, M., et al. (2016) · European Heart Journal - Quality of Care and Clinical Outcomes · doi:10.1093/ehjqcco/qcv022 · Cited by 5
Schuering, C. L., Zwaans, V. I. T., Huang, A., Köhler-Seuster, M., von Mackensen, J. K. R., Iske, J., Stein, J., Kaemmel, J., Heck, R., Starck, C. T., et al. (2025) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2025.1650138 · Cited by 4
Huded, C. P., Spertus, J., Jones, P. G., O'Brien, S. M., Mark, D. B., Bangalore, S., Stone, G., Williams, D., White, H., Boden, W. E., et al. (2025) · Circulation · doi:10.1161/circulationaha.125.073591 · Cited by 4
Coronary Artery Bypass Grafting: A Review of Short- and Long-Term Outcomes
Adeyemi, A. M., Berman, L., Staroselsky, M., Cordero, D., Hai, O. Y., Makaryus, A., & Zeltser, R. (2025) · International Journal of Angiology · doi:10.1055/a-2655-2479 · Cited by 4
Efficacy and risks of drug-coated balloon treatment for coronary artery disease: A meta-analysis
Bai, X., Shen, C., Zhang, W.-Z., Yu, T., & Jiang, J. (2023) · Heliyon · doi:10.1016/j.heliyon.2023.e22224 · Cited by 4
“During balloon inflation, this drug is transferred to the intimal layer of the vessel wall, facilitating rapid delivery of lipophilic medication and inhibiting smooth muscle cell proliferation [8,9].”
Background
Metadata
- Authors
- Abdallah, M. S.
- Affiliations
- Saint Luke's Hospital (US)
- Corresponding author
- Abdallah, Mouin S.
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2013-10-16
- Volume
- 310
- Issue
- 15
- Pages
- 1581
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC4370776
- OpenAlex
- W2025139632
- Cited by
- 169
- References
- 43
- Citations by year
- 2026: 8 · 2025: 14 · 2024: 6 · 2023: 9 · 2022: 16 · 2021: 15 · 2020: 15 · 2019: 12 · 2018: 11 · 2017: 17 · 2016: 18 · 2015: 14 · 2014: 13 · 2013: 1
- FWCI
- 15.13
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute (U01 01HL071988, R01HL092989, P50HL077113, U01HL071988, U01 01HL092989)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Coronary Interventions and Diagnostics
- Health Sciences › Medicine › Surgery › Cardiac and Coronary Surgery Techniques
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Keywords
- coronary artery bypass grafting, percutaneous coronary intervention, drug-eluting stents, diabetes mellitus, multivessel coronary artery disease, quality of life, Seattle Angina Questionnaire, angina frequency, physical limitations, health status, FREEDOM trial, revascularization, patient-reported outcomes, stroke risk, myocardial infarction, mortality
- MeSH terms
- Aged, Angina Pectoris, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Female, Health Status, Humans, Male, Middle Aged, Quality of Life, Treatment Outcome, Diabetes Complications, Drug-Eluting Stents, Percutaneous Coronary Intervention
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