Revascularization Strategies in Patients With Type 2 Diabetes
Revascularization Strategies in Patients With Type 2 Diabetes
Until recently, the question of whether to implement optimal medical therapy (OMT) only versus revascularization in stable CAD in diabetics was not well addressed with any large-scale, randomized trials. The bypass angioplasty revascularization investigation 2 diabetes (BARI 2D) study randomized 2368 patients with DM and stable CAD to intensive medical therapy alone or intensive medical therapy with revascularization. Patients were randomized to revascularization versus no revascularization but the choice of coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) was determined by a physician's evaluation of a patient's baseline characteristics. All patients were treated with target goals of glycated hemoglobin <7%, low-density lipoprotein (LDL) cholesterol <100 mg/dl, and blood pressure ≤130/80. In comparing the revascularization group and the OMT-only group at 5 years, there was no difference in the primary end point of death from any cause, nor was there a difference in the secondary end point of major cardiovascular events (MACE), defined as a composite of death, MI or stroke. However, when CABG versus OMT was compared with PCI versus OMT, only CABG patients had significantly fewer MACE, mainly driven by fewer subsequent revascularizations. Notably, patients in the CABG treatment arm had worse CAD, with significantly more three-vessel disease, proximal left anterior descending artery (LAD) disease, and more total chronic total occlusions than in the PCI treatment arm. Furthermore, these patients were more likely to have had a prior MI and less likely to have had past revascularization.
In a prior study of the same population, revascularization resulted in significant improvement in angina symptoms in diabetics at 3 years defined as worsening angina or freedom from angina. However, this difference became insignificant by 5 years until the revascularization group was stratified by CABG versus PCI. Similar to the BARI 2D study, only CABG group patients did better, experiencing a sustained symptomatic benefit for up to 4 years for worsening angina and throughout 5 years for freedom from angina. Although the BARI 2D study did not directly compare CABG and PCI, it showed that patients with more extensive stable coronary disease may benefit from CABG in terms of angina symptoms. Furthermore, at 5 years, OMT may be a safe alternative to revascularization in DM patients with chronic CAD in terms of major adverse cardiac events. There are no long-term follow-up data available on this cohort and the enrollment period for the study occurred prior to the drug-eluting stent (DES) era.
Optimal Medical Therapy versus Revascularization in Stable Disease
Until recently, the question of whether to implement optimal medical therapy (OMT) only versus revascularization in stable CAD in diabetics was not well addressed with any large-scale, randomized trials. The bypass angioplasty revascularization investigation 2 diabetes (BARI 2D) study randomized 2368 patients with DM and stable CAD to intensive medical therapy alone or intensive medical therapy with revascularization. Patients were randomized to revascularization versus no revascularization but the choice of coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) was determined by a physician's evaluation of a patient's baseline characteristics. All patients were treated with target goals of glycated hemoglobin <7%, low-density lipoprotein (LDL) cholesterol <100 mg/dl, and blood pressure ≤130/80. In comparing the revascularization group and the OMT-only group at 5 years, there was no difference in the primary end point of death from any cause, nor was there a difference in the secondary end point of major cardiovascular events (MACE), defined as a composite of death, MI or stroke. However, when CABG versus OMT was compared with PCI versus OMT, only CABG patients had significantly fewer MACE, mainly driven by fewer subsequent revascularizations. Notably, patients in the CABG treatment arm had worse CAD, with significantly more three-vessel disease, proximal left anterior descending artery (LAD) disease, and more total chronic total occlusions than in the PCI treatment arm. Furthermore, these patients were more likely to have had a prior MI and less likely to have had past revascularization.
In a prior study of the same population, revascularization resulted in significant improvement in angina symptoms in diabetics at 3 years defined as worsening angina or freedom from angina. However, this difference became insignificant by 5 years until the revascularization group was stratified by CABG versus PCI. Similar to the BARI 2D study, only CABG group patients did better, experiencing a sustained symptomatic benefit for up to 4 years for worsening angina and throughout 5 years for freedom from angina. Although the BARI 2D study did not directly compare CABG and PCI, it showed that patients with more extensive stable coronary disease may benefit from CABG in terms of angina symptoms. Furthermore, at 5 years, OMT may be a safe alternative to revascularization in DM patients with chronic CAD in terms of major adverse cardiac events. There are no long-term follow-up data available on this cohort and the enrollment period for the study occurred prior to the drug-eluting stent (DES) era.
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