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The Role of Revascularization Versus Medical Therapy in Patients With Type 2 Diabetes Mellitus and Coronary Artery Disease

Current Diabetes Reports volume 10, pages 10–15 (2010)Cite this article

Abstract

Patients with type 2 diabetes mellitus (T2DM) are at increased risk for cardiovascular clinical events, adverse nonfatal outcomes, and death. There has been considerable improvement in the medical management of patients with T2DM in an attempt to alter the metabolic cascade that is triggered by insulin resistance. Recent trials have demonstrated that medical management of patients with diabetes mellitus and stable coronary artery disease (CAD) is equivalent to revascularization in terms of morality benefit and rates of major adverse cardiovascular events, particularly in patients who do not have extensive CAD. Nonetheless, in those diabetic patients with additional high-risk features including left main disease, reduced left ventricular ejection fraction (LVEF), severe ischemia, or acute coronary syndrome, revascularization remains the best treatment option. Although the evidence still supports coronary artery bypass grafting (CABG) as the standard of care for revascularization of diabetic patients with multivessel CAD and/or reduced LVEF, percutaneous coronary intervention (PCI) with drug-eluting stents (DES) has resulted in at least partial closure of the gap in benefit between surgery and catheter-based intervention. Ongoing trials of diabetic patients with CAD randomized to PCI or CABG will help further elucidate the role of PCI with DES as a potential revascularization option for this patient population.

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References

Papers of particular interest, published recently, have been highlighted as:•Of importance •• Of major importance

  1. Cowie CC, Rust KF, Byrd-Holt DD, et al.: Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: NHANES 1999–2002. Diabetes Care 2006, 29:1263–1268.

    Article  PubMed  Google Scholar 

  2. NHANES 2003–2006, National Center for Health Statistics, Centers for Disease Control and Prevention. Available at http://www.cdc.gov/nchs/nhanes.htm. Accessed December 2009.

  3. 2004–2006 National Health Interview Survey (NHIS), National Center for Health Statistics, Centers for Disease Control and Prevention. Available at http://www.cdc.gov/nchs/nhis.htm. Accessed December 2009.

  4. Wild S, Roglic G, Green A, et al.: Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004, 27:1047–1053.

    Article  PubMed  Google Scholar 

  5. Kannel W, McGee D: Diabetes and cardiovascular risk factors: the Framingham Study. Circulation 1979, 59:8–13.

    CAS  PubMed  Google Scholar 

  6. Stamler J, Vaccaro O, Neaton JD, Wentworth D: Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention TriaI. Diabetes Care 1993, 16:434–444.

    Article  CAS  PubMed  Google Scholar 

  7. Lee CD, Folsom AR, Pankow JS, Brancati FL: Cardiovascular events in diabetic and nondiabetic adults with or without history of myocardial infarction. Circulation 2004, 109:855–860.

    Article  PubMed  Google Scholar 

  8. Juutilainen A, Lehto S, Ronnemaa T, et al.: Type 2 diabetes as a "coronary heart disease equivalent": an 18-year prospective population-based study in Finnish subjects. Diabetes Care 2005, 28:2901–2907.

    Article  PubMed  Google Scholar 

  9. Haffner SM, Lehto S, Ronnemaa T, et al.: Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998, 339:229–234.

    Article  CAS  PubMed  Google Scholar 

  10. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): final report. Circulation 2002, 106:3143–3421.

    Google Scholar 

  11. Vlietstra RE, Kronmal RA, Frye RL, et al.: Factors affecting the extent and severity of coronary artery disease in patients enrolled in the coronary artery surgery study. Arteriosclerosis 1982, 2:208–215.

    CAS  PubMed  Google Scholar 

  12. Goraya TY, Leibson CL, Palumbo PJ: Coronary atherosclerosis in diabetes mellitus: a population-based autopsy study. J Am Coll Cardiol 2002, 40:946–953.

    Article  PubMed  Google Scholar 

  13. Hueb W, Gersh BJ, Costa F, et al.: Impact of diabetes on five-year outcomes of patients with multivessel coronary artery disease. Ann Thorac Surg 2007, 83:93–99.

    Article  PubMed  Google Scholar 

  14. Mathew V, Gersh BJ, Williams BA, et al.: Outcomes in patients with diabetes mellitus undergoing percutaneous coronary intervention in the current era: a report from the Prevention of REStenosis with Tranilast and its Outcomes (PRESTO) trial. Circulation 2004, 109:476–480.

    Article  PubMed  Google Scholar 

  15. Eckel RH, Wassef M, Chait A, et al.: Prevention Conference VI: Diabetes and Cardiovascular Disease: Writing Group II: pathogenesis of atherosclerosis in diabetes. Circulation 2002, 105:e138–e143.

    Article  PubMed  Google Scholar 

  16. Moreno PR, Murcia AM, Palacios IF, et al.: Coronary composition and macrophage infiltration in atherectomy specimens from patients with diabetes mellitus. Circulation 2000, 102:2180–2184.

    CAS  PubMed  Google Scholar 

  17. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators [no authors listed]. N Engl J Med 1996, 335:217–225. (Published erratum appears in N Engl J Med 1997, 336:147.)

  18. •• BARI Investigators: The final 10-year follow-up results from the BARI randomized trial. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. J Am Coll Cardiol 2007, 49:1600–1606. BARI was a major trial randomizing patients with multivessel CAD to revascularization with PCI or CABG. The trial showed a mortality benefit with CABG over PCI, which persisted at long-term follow-up of 10 years. The major limitation is that the trial was conducted before the modern era of PCI with DES.

    Article  Google Scholar 

  19. • Hlatky MA, Boothroyd DB, Bravata DM, et al.: Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet 2009, 373:1190–1197. This was an important, recently published meta-analysis evaluating previous trials of PCI versus CABG in patients with multivessel CAD. The meta-analysis supported the superiority of CABG over PCI in the subset of patients with diabetes mellitus by showing a mortality benefit. The drawback is that many previous trials used older, inferior PCI techniques.

    Article  PubMed  Google Scholar 

  20. •• BARI 2D Study Group: A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med 2009, 360:2503–2515. This trial is the first in the modern era of revascularization with DES to randomize diabetic patients with CAD to medical therapy alone or to revascularization with PCI or CABG. The results reinforced those from COURAGE and expanded the findings to the higher-risk diabetic population by demonstrating equivalent mortality between optimal medical therapy alone and revascularization with PCI or CABG (in those without high-risk features such as left main disease).

    Article  Google Scholar 

  21. •• Boden WE, O’Rourke RA, Teo KK, et al.: Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007, 356:1503–1516. COURAGE was the first large, randomized trial of patients with stable CAD in the modern era of PCI with stenting that evaluated outcomes with OMT alone versus OMT plus PCI. The results demonstrated no benefit to PCI over OMT alone in terms of mortality or prevention of adverse cardiovascular events; COURAGE has had a large influence on clinical practice by supporting an initial strategy of medical therapy alone in patients with stable CAD.

    Article  CAS  PubMed  Google Scholar 

  22. Detre K, Murphy ML, Hultgren H: Effect of coronary bypass surgery on longevity in high and low risk patients: report from the V.A. Cooperative Coronary Surgery Study. Lancet 1977, 2:1243–1245.

    Article  CAS  PubMed  Google Scholar 

  23. Yusuf S, Zucker D, Peduzzi P, et al.: Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994, 344:563–570.

    Article  CAS  PubMed  Google Scholar 

  24. Keeley EC, Boura JA, Grines CL: Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003, 361:13–20.

    Article  PubMed  Google Scholar 

  25. Invasive compared with non-invasive treatment in unstable coronary-artery disease. FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators [no authors listed]. Lancet 1999, 354:708–715.

  26. Cannon CP, Weintraub WS, Demopoulos LA, et al.: Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001, 344:1879–1887.

    Article  CAS  PubMed  Google Scholar 

  27. Fox KA, Poole-Wilson PA, Henderson RA, et al.: Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial: Randomized Intervention Trial of unstable Angina. Lancet 2002, 360:743–751.

    Article  CAS  PubMed  Google Scholar 

  28. Mehta SR, Cannon CP, Fox KA, et al.: Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA 2005, 293:2908–2917.

    Article  CAS  PubMed  Google Scholar 

  29. Zairis MN, Lyras AG, Makrygiannis SS, et al.: Type 2 diabetes and intravenous thrombolysis outcome in the setting of ST elevation myocardial infarction. Diabetes Care 2004, 27:967–971.

    Article  PubMed  Google Scholar 

  30. Flaherty JD, Davidson CJ: Diabetes and coronary revascularization. JAMA 2005, 293:1501–1508.

    Article  CAS  PubMed  Google Scholar 

  31. Brener SJ, Lytle BW, Casserly IP, et al.: Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features. Circulation 2004, 109:2290–2295.

    Article  PubMed  Google Scholar 

  32. Niles NW, McGrath PD, Malenka D, et al.: Northern New England Cardiovascular Disease Study Group. Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study. J Am Coll Cardiol 2001, 37:1008–1015.

    Article  CAS  PubMed  Google Scholar 

  33. Pell JP, Pell AC, Jeffrey RR, et al.: Comparison of survival following coronary artery bypass grafting vs. percutaneous coronary intervention in diabetic and non-diabetic patients: retrospective cohort study of 6320 procedures. Diabet Med 2004, 21:790–792.

    Article  CAS  PubMed  Google Scholar 

  34. Hoffman SN, TenBrook JA, Wolf MP: A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one-to eight-year outcomes. J Am Coll Cardiol 2003, 41:1293–1304.

    Article  PubMed  Google Scholar 

  35. Dibra A, Kastrati A, Mehilli J, et al.: Paclitaxel-eluting or sirolimus-eluting stents to prevent restenosis in diabetic patients. ISAR-DIABETES Study Investigators. N Engl J Med 2005, 353:663–670.

    CAS  Google Scholar 

  36. Moussa I, Leon MB, Baim DS, et al.: Impact of sirolimus-eluting stents on outcome in diabetic patients: a SIRIUS (SIRolImUS-coated Bx Velocity balloon-expandable stent in the treatment of patients with de novo coronaryartery lesions) substudy. Circulation 2004, 109:2273–2278.

    Article  CAS  PubMed  Google Scholar 

  37. Baumgart D, Klauss V, Baer F, et al.: One-year results of the SCORPIUS study: a German multicenter investigation on the effectiveness of sirolimus-eluting stents in diabetic patients. J Am Coll Cardiol 2007, 50:1627–1634.

    Article  PubMed  Google Scholar 

  38. Jimenez-Quevedo P, Sabate M, Angiolillo DJ, et al.: Long-term clinical benefit of sirolimus-eluting stent implantation in diabetic patients with de novo coronary stenoses: long-term results of the DIABETES trial. Eur Heart J 2007, 28:1946–1952.

    Article  PubMed  Google Scholar 

  39. Kirtane AJ, Ellis SG, Dawkins KD, et al.: Paclitaxel-eluting coronary stents in patients with diabetes mellitus: pooled analysis from 5 randomized trials. J Am Coll Cardiol 2008, 51:708–715.

    Article  CAS  PubMed  Google Scholar 

  40. Daemen J, Kuck KH, Macaya C, et al.: Multivessel coronary revascularization in patients with and without diabetes mellitus 3-year follow-up of the ARTS-II (Arterial Revascularization Therapies Study-Part II) trial. J Am Coll Cardiol 2008, 52:1957–1967.

    Article  PubMed  Google Scholar 

  41. Serruys PW, Morice MC, Kappetein AP, et al.: Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009, 360:961–972.

    Article  CAS  PubMed  Google Scholar 

  42. Kapur A, Malik IS, Bagger JP, et al.: The Coronary Artery Revascularisation in Diabetes (CARDia) trial: background, aims, and design. Am Heart J 2005, 149:13–19.

    Article  CAS  PubMed  Google Scholar 

  43. European Society of Cardiology: Coronary Artery Revascularisation in Diabetes. The CARDia trial. Hot Line II. Available at http://www.escardio.org/congresses/esc2008/congress-reports/Pages/1694–1695-kapur.aspx. Accessed December 2009.

  44. Farkouh ME, Dangas G, Leon MB, et al.: Design of the Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease (FREEDOM) Trial. Am Heart J 2008, 155:215-223.

    Article  PubMed  Google Scholar 

  45. Goy JJ, Kaufmann U, Hurni M, et al.: 10-year follow-up of a prospective randomized trial comparing bare-metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial. J Am Coll Cardiol 2008, 52:815–817.

    Article  PubMed  Google Scholar 

  46. Diegeler A, Thiele H, Falk V, et al.: Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery. N Engl J Med 2002, 347:561–566.

    Article  PubMed  Google Scholar 

  47. Drenth DJ, Veeger NJ, Winter JB, et al.: A prospective randomized trial comparing stenting with off-pump coronary surgery for high-grade stenosis in the proximal left anterior descending coronary artery: three-year follow-up. J Am Coll Cardiol 2002, 40:1955–1960.

    Article  PubMed  Google Scholar 

  48. Thiele H, Oettel S, Jacobs S, et al.: Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: a 5-year follow-up. Circulation 2005, 112:3445–3450.

    Article  CAS  PubMed  Google Scholar 

  49. Taggart DP: PCI or CABG in coronary artery disease? Lancet 2009, 373:1150–1152.

    Article  PubMed  Google Scholar 

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Affiliations

  1. Division of Cardiology, Buffalo General Hospital, 100 High Street, Buffalo, NY, 14203, USA

    Brian J. Page, Dmitriy Kireyev & William E. Boden

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  1. Brian J. Page
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  2. Dmitriy Kireyev
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  3. William E. Boden
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Correspondence to William E. Boden.

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Page, B.J., Kireyev, D. & Boden, W.E. The Role of Revascularization Versus Medical Therapy in Patients With Type 2 Diabetes Mellitus and Coronary Artery Disease. Curr Diab Rep 10, 10–15 (2010). https://doi.org/10.1007/s11892-009-0091-9

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  • DOI: https://doi.org/10.1007/s11892-009-0091-9

Keywords

  • Type 2 diabetes mellitus
  • Coronary artery disease (CAD)
  • Medical therapy
  • Revascularization
  • PCI
  • CABG