Prognostic impact of the presence and absence of angina on mortality and cardiovascular outcomes in patients with type 2 diabetes and stable coronary artery disease: results from the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial

Abstract

Objectives: The purpose of this analysis was to assess in patients with type 2 diabetes and stable coronary artery disease (CAD) whether the risk of all-cause mortality and cardiovascular events varied according to the presence or absence of angina and angina equivalent symptoms.

Background: Data on the prognostic value of symptoms in these patients are limited.

Methods: Post-hoc analysis was performed in 2,364 patients with type 2 diabetes and documented CAD enrolled in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial to determine the occurrence of death and composite of death, myocardial infarction, and stroke during a 5-year follow-up according to cardiac symptoms at baseline.

Results: There were 1,434 patients with angina (A), 506 with angina equivalents (E), and 424 with neither of these (N). The cumulative death rates (total 316) were 12% in A, 14% in E, and 10% in N (p = 0.3), and cardiovascular composite rates (total 548) were 24% in A, 24% in E, and 21% in N (p = 0.5). Compared with N, the hazard ratios adjusted for confounders were not different for death in A (1.11; 99% CI: 0.81 to 1.53) and E (1.17; 99% CI: 0.81 to 1.68) or for cardiovascular events in A (1.17; 99% CI: 0.92 to 1.50) and E (1.11; 99% CI: 0.84 to 1.48).

Conclusions: Whatever their symptom status, patients with type 2 diabetes and stable CAD were at similar risk of cardiovascular events and death. These findings suggest that these patients may be similarly managed in terms of risk stratification and preventive therapies. (Bypass Angioplasty Revascularization Investigation 2 Diabetes [BARI 2D]; NCT00006305).

Figure 1. Kaplan-Meier Event Rates According to Symptom Status at Entry

The events are the first occurrence of the composite outcome (all-cause death, nonfatal myocardial infarction [MI], or nonfatal stroke), death; MI is nonfatal MI, and stroke is nonfatal stroke. None represents patients with neither angina nor angina equivalent (Equiv.). There were no differences among the 3 groups for each event according to log-rank test. K-M =Kaplan-Meier.

Figure 2. Kaplan-Meier Rates of First Coronary Revascularization According to CCS Angina Grades

Participants randomized to the optimal medical strategy (MED) with Canadian Cardiovascular Society (CCS) angina grades III and IV had a higher rate of revascularization compared with participants with CCS angina grades I and II. For participants randomized to the prompt revascularization strategy (REV), only those with CCS angina grade IV had a higher rate of revascularization compared with the 3 other groups. K-M =Kaplan-Meier.