Integrated management of patients with diabetes mellitus and ischemic heart disease: PCI, CABG, and medical therapy

Modern coronary revascularization strategies are based on studies performed in the 1970s and 1980s that compared coronary artery bypass surgery with standard medical therapy available at the time. Studies comparing surgical and percutaneous revascularization followed, demonstrating similar long-term outcome among thousands of randomized patients. The largest of these trials, the Bypass Angioplasty Revascularization Investigation (BARI), cast doubt on the generalizability of these findings to all subgroups, finding that patients with diabetes mellitus and multivessel disease had worse long-term outcome with an initial strategy of percutaneous transluminal coronary angioplasty (PTCA). Indeed, patients with diabetes mellitus are at increased risk for cardiovascular morbidity and mortality, while the benefit of standard therapies in these patients is attenuated by the underlying metabolic abnormalities and significant comorbidities associated with the diabetic state. However, surgical and percutaneous revascularization techniques continue to evolve. Similarly, modern medical therapy is markedly superior to that available during these early studies, with demonstrable benefit in primary and secondary prevention of vascular events in both diabetic and nondiabetic patients. Ongoing trials will define the impact of current treatment modalities in this important and growing population.