Burton E Sobel1. 1. Department of Medicine, University of Vermont College of Medicine, University of Vermont, Colchester Research Facility, Colchester, Vermont 05446, USA. burton.sobel@uvm.edu
Abstract
OBJECTIVES: This Perspective reviews the results of early and contemporary studies evaluating the safety and efficacy of coronary revascularization in patients with diabetes. It also addresses the implications of some of the data in the Bypass Angioplasty Revascularization Investigation in type 2 diabetes (BARI 2D) trial. METHODS: Review of the literature and discussion of the implications of results in the BARI 2D trial. RESULTS: Patients with diabetes benefit from revascularization by coronary thrombolysis, percutaneous transluminal coronary angioplasty, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG). However, with each intervention the benefit is less and the risks and complications are greater than in patients without diabetes. Revascularization for treatment of ST elevation myocardial infarction increases survival. When used for treatment of non-ST elevation myocardial infarction or unstable angina, it does not except in those at very high risk. In patients with chronic, symptomatic coronary artery disease, long-term mortality is comparable after CABG or PCI. However, the incidence of major adverse cardiac events is greater after PCI primarily because of the need for more subsequent revascularization procedures. Both interventions relieve symptoms, but neither improves survival except in patients at high risk. In patients with clinically stable chronic coronary disease, survival after CABG or PCI is comparable with that in patients treated with optimal medical therapy alone. Accordingly, evaluation for revascularization can be deferred until signs and symptoms worsen except in patients at high risk. In patients at high risk survival after promptly implemented CABG is greater than that with optimal medical therapy, especially when the diabetes is being treated with insulin sensitizing agents.
OBJECTIVES: This Perspective reviews the results of early and contemporary studies evaluating the safety and efficacy of coronary revascularization in patients with diabetes. It also addresses the implications of some of the data in the Bypass Angioplasty Revascularization Investigation in type 2 diabetes (BARI 2D) trial. METHODS: Review of the literature and discussion of the implications of results in the BARI 2D trial. RESULTS:Patients with diabetes benefit from revascularization by coronary thrombolysis, percutaneous transluminal coronary angioplasty, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG). However, with each intervention the benefit is less and the risks and complications are greater than in patients without diabetes. Revascularization for treatment of ST elevation myocardial infarction increases survival. When used for treatment of non-ST elevation myocardial infarction or unstable angina, it does not except in those at very high risk. In patients with chronic, symptomatic coronary artery disease, long-term mortality is comparable after CABG or PCI. However, the incidence of major adverse cardiac events is greater after PCI primarily because of the need for more subsequent revascularization procedures. Both interventions relieve symptoms, but neither improves survival except in patients at high risk. In patients with clinically stable chronic coronary disease, survival after CABG or PCI is comparable with that in patients treated with optimal medical therapy alone. Accordingly, evaluation for revascularization can be deferred until signs and symptoms worsen except in patients at high risk. In patients at high risk survival after promptly implemented CABG is greater than that with optimal medical therapy, especially when the diabetes is being treated with insulin sensitizing agents.