Choice of initial medical therapy vs. prompt coronary revascularization in patients with type 2 diabetes and stable ischemic coronary disease with special emphasis on the BARI 2D trial results

Abstract

Purpose of review: To determine whether a strategy of prompt coronary revascularization as compared with an initial strategy of intensive optimal medical therapy (OMT) in patients with type 2 diabetes and stable coronary artery disease (CAD) prevents major adverse cardiac outcomes.

Recent findings: Randomized controlled clinical trials comparing a strategy of prompt coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) or medical therapy in patients with type 2 diabetes are reviewed with special emphasis on the Bypass Angioplasty Revascularization Investigation 2D trial. An initial strategy of PCI or CABG alleviates symptoms and improves quality of life more than an initial strategy of OMT. However, an initial strategy of PCI in patients with less extensive CAD does not significantly reduce death or myocardial infarction. Patients with more extensive CAD in whom a more complete coronary revascularization can be achieved with CABG have less subsequent myocardial infarction, a complication associated with increased mortality, than those treated with initial OMT.

Summary: In many patients with type 2 diabetes and stable CAD in whom angina symptoms are controlled, OMT alone should be the first-line strategy. In patients with more extensive coronary disease, prompt CABG, in the absence of contraindications, OMT, and an insulin sensitization strategy are a preferred therapeutic strategy to reduce the incidence of myocardial infarction.