The treatment of stable coronary artery disease in diabetics: the battle between "conservative" and "invasive" continues.


D iabetes mellitus (DM) and cardiovascular disease are nowadays considered to be two sides of the same coin. Patients with type 2 DM are at clearly higher risk (2-4 times) of cardiovascular events and death compared with non-diabetics. In patients with stable coronary artery disease (CAD) and type 2 DM there are two important questions that have gone begging for years now: 1) What is the best strategy for the treatment of ischaemia, which is known to be the main cause of death in diabetics with CAD? 2) What should be the treatment for insulin resistance, the basic mechanism underlying DM that is accompanied by cardiovascular complications? Recently, the results of the BARI 2D trial were announced. This study was designed to seek answers to the following specific questions: a) to what extent do anti-diabetic insulin-sensitising drugs (metformin and thiazolidinediones) stop or slow the development of atherosclerotic CAD compared to insulin-providing medication (sulfonylureas, insulin); and b) to what degree can reperfusion in diabetics reduce mortality and cardiovascular events compared to medical treatment? The study randomised 2368 patients with type 2 DM and stable CAD along two axes: ñ either prompt reperfusion or intensive medical therapy. ñ control of DM with either insulin-sensitisation or insulin-provision therapy. The choice of reperfusion method—percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)—was made by the treating physician for each individual patient. The patients in the medication arm were treated according to current guidelines to a target glycated haemoglobin of <7%, low-density lipoprotein (LDL) cholesterol <100 mg/dL and blood pressure <130/80 mm Hg. Revascularisation was only performed in this group if there was worsening of angina, ischaemia, or acute coronary syndrome. The primary endpoint was death from any cause, with a secondary composite endpoint that included death, myocardial infarction and stroke. The mean follow-up duration was 5.3 years.

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@article{Pyrgakis2009TheTO, title={The treatment of stable coronary artery disease in diabetics: the battle between "conservative" and "invasive" continues.}, author={Vlassis N Pyrgakis}, journal={Hellenic journal of cardiology : HJC = Hellēnikē kardiologikē epitheōrēsē}, year={2009}, volume={50 4}, pages={341-2} }