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Revascularization strategies in patients with diabetes.

To the Editor: In reporting the results of the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial, Farkouh et al. (Dec. 20 issue)1 suggest that in patients with diabetes and advanced coronary artery disease, coronary-artery bypass grafting (CABG) was superior to percutaneous coronary intervention (PCI). The benefit of CABG was driven by differences in rates of myocardial infarction and death from any cause. However, rates of cardiovascular death were similar in the two groups, whereas the rate of stroke was significantly higher after CABG.1 At 30 days, the primary outcome had occurred in fewer patients after PCI. The main driver of the difference in the primary composite outcome was the higher incidence of myocardial infarction after PCI. However, beyond 30 days after any revascularization procedure, myocardial infarction was defined as only a typical increase in the troponin level (more than one value exceeding the necrosis boundary).1,2 Most of these late myocardial infarctions (accounting for 82% of those seen in the PCI group) might actually have been relatively minor episodes of myonecrosis. The clinical relevance of these events, as compared with other major components of the primary outcome, including stroke, remains largely speculative. Accordingly, additional information on the types of myocardial infarction in the two groups would be critical to better interpret the study. Otherwise, the superiority of CABG over PCI could be questioned, even in this challenging scenario.