Revascularization Strategies in Patients With Type 2 Diabetes
Revascularization Strategies in Patients With Type 2 Diabetes
Almost 20 years ago, the BARI trial suggested an advantage of CABG over PTCA in diabetics with MVD. There has been an evolution of trials from BARI 2D to CARDia to SYNTAX, and now FREEDOM all confirming what is already known – that diabetics have worse, more diffuse CAD; and are better served by CABG as compared with PCI. Results of the FREEDOM trial should lay any remaining controversy to rest. The more pressing issue is that medical management of these patients remains woefully inadequate. The majority of patients almost never achieve the goal levels of glycated hemoglobin, blood pressure or LDL targeted, even in the clinical trial setting. For example, BARI 2D was a well-designed trial that compared outcomes in DM patients receiving OMT versus medical therapy with revascularization. Yet, even in the context of a clinical trial with good follow-up, the majority of patients had a glycated hemoglobin >7.0% and blood pressure >130/80 (58 and 52%, respectively). Similarly, in FREEDOM, the average glycated hemoglobin was 7.8% for both the PCI and CABG groups. Reforms in the US healthcare offer exciting opportunities to place greater focus on preventive therapies and to truly optimize medical management.
Expert Commentary
Almost 20 years ago, the BARI trial suggested an advantage of CABG over PTCA in diabetics with MVD. There has been an evolution of trials from BARI 2D to CARDia to SYNTAX, and now FREEDOM all confirming what is already known – that diabetics have worse, more diffuse CAD; and are better served by CABG as compared with PCI. Results of the FREEDOM trial should lay any remaining controversy to rest. The more pressing issue is that medical management of these patients remains woefully inadequate. The majority of patients almost never achieve the goal levels of glycated hemoglobin, blood pressure or LDL targeted, even in the clinical trial setting. For example, BARI 2D was a well-designed trial that compared outcomes in DM patients receiving OMT versus medical therapy with revascularization. Yet, even in the context of a clinical trial with good follow-up, the majority of patients had a glycated hemoglobin >7.0% and blood pressure >130/80 (58 and 52%, respectively). Similarly, in FREEDOM, the average glycated hemoglobin was 7.8% for both the PCI and CABG groups. Reforms in the US healthcare offer exciting opportunities to place greater focus on preventive therapies and to truly optimize medical management.
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