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Editorial
Deferral of PCI, a safe strategy in diabetic patients with chronic coronary syndromes
  1. William S Weintraub1,
  2. William E Boden2,3
  1. 1 Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
  2. 2 Medicine, VA Boston Health Care System West Roxbury Campus, West Roxbury, Massachusetts, USA
  3. 3 Department of Cardiology, Boston University School of Medicine, Boston, Massachusetts, USA
  1. Correspondence to Dr William S Weintraub, Cardiology, MedStar Washington Hospital Center, Washington, DC 20010, USA; William.s.weintraub{at}medstar.net

https://doi.org/10.1136/heartjnl-2020-317363

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    What is the efficacy and value of percutaneous coronary intervention (PCI) in patients with chronic coronary syndromes (CCS) and, especially in patients with diab etes? This has been a subject of randomised trials since the Emory Angioplasty Surgery Trial (EAST), which was published over 25 years ago.1 EAST was too small to evaluate subgroups. The larger Bypass and Angioplasty Intervention (BARI) trial was the first to show the clinical benefit of coronary artery bypass graft (CABG) surgery compared with balloon angioplasty in long-term mortality in patients with diabetes.2 BARI was the impetus for Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes (BARI 2D), which evaluated revascularisation in 2368 patients with CCS with diabetes; 1605 were randomised to PCI or medical therapy and 763 with more severe coronary artery disease (CAD) to CABG or medical therapy.3 While compared with medical therapy there was no overall advantage to revascularisation in reducing the primary endpoint of all-cause mortality, there was a decrease in the secondary composite of death, myocardial infarction (MI) or stroke in the CABG (22.4%) versus medical therapy group at 5 years (30.5%, p=0.01). By contrast, in the PCI subgroup, there was a trend towards increased mortality, MI and stroke with PCI (23.0%) compared with medical therapy (21.1%, p=0.015). Thus, BARI 2D largely confirmed the results of the earlier Clinical Outcomes Utilising Revascularisation and Aggressive druG Evaluation (COURAGE) trial of 2287 patients with CCS, of whom 34% had diabetes, which showed no advantage of PCI compared with optimal medical therapy (OMT) for the primary endpoint of death or MI at 4.6 years.4

    Similarly, there has been a long-standing belief that moderate or severe reversible ischaemia in patients with CCS would identify a high-risk subset which might benefit from revascularisation. Non-randomised, observational studies have suggested that with greater …

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    Footnotes

    • Contributors WW wrote the editorial and edited the drafts from initial to final. WB consulted with WW on the content and edited the drafts.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Patient consent for publication Not required.

    • Provenance and peer review Commissioned; internally peer reviewed.

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