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Coronary revascularisation in the patient with diabetes: balancing risk and benefit
  1. Martin K Rutter1,2,
  2. Richard W Nesto3,4
  1. 1Cardiovascular Research Group, School of Biomedicine, University of Manchester, Manchester, UK
  2. 2Manchester Diabetes Centre, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
  3. 3The Lahey Clinic, Burlington, Massachusetts, USA
  4. 4Tufts Medical School, Massachusetts, USA
  1. Correspondence to Martin K Rutter, Cardiovascular Research Group, Core Technology Facility, 46 Grafton Street, Manchester M13 9NT, UK; martin.rutter{at}manchester.ac.uk

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Introduction and aims

There has been a remarkable reduction in the mortality attributable to coronary heart (CHD) disease in patients with type 2 diabetes mellitus (T2DM), which is, in part, due to the evolution of prevention therapies including more aggressive risk factor control.1 2 Nevertheless, diabetes still confers twice the mortality for CHD compared to patients without diabetes.

Although the benefit of revascularisation is established in patients experiencing acute coronary syndromes, the role of revascularisation, and, more specifically, the modality (coronary artery bypass surgery (CABG) versus angioplasty (PCI)), is not defined in patients with diabetes presenting with stable angina. In this review, two important clinical questions are addressed in patients with diabetes:

  1. In medically-treated non-ACS patients, should revascularisation (CABG or PCI) be offered initially or should it be delayed?

  2. When does CABG offer benefits over PCI?

Important contributions made to our understanding of this area by the Bypass Angioplasty Revascularisation Investigation 2 Diabetes (BARI 2D) trial are highlighted,3 current gaps in our knowledge are identified and an ongoing clinical trial is introduced that aims to address these gaps.

Medical care, including the management of diabetes will not be discussed. This contribution relates primarily to patients with T2DM, who make up the majority of patients with diabetes who have CHD.

Revascularisation versus medical therapy in diabetes

The BARI 2D trial was designed to answer the first question highlighted above in patients with diabetes.3 In the general population, prior revascularisation trials demonstrated a reduced risk of death and myocardial infarction (MI) in high-risk patients, but the results were inconsistent in those with less severe disease.4–6

For example, the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial showed that in patients with stable coronary artery disease (CAD), initial management by angioplasty (PCI) did not improve outcomes when added to optimal medical therapy.4 These results were …

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