The Role of Revascularization Versus Medical Therapy in Patients With Type 2 Diabetes Mellitus and Coronary Artery Disease

Abstract

Patients with type 2 diabetes mellitus (T2DM) are at increased risk for cardiovascular clinical events, adverse nonfatal outcomes, and death. There has been considerable improvement in the medical management of patients with T2DM in an attempt to alter the metabolic cascade that is triggered by insulin resistance. Recent trials have demonstrated that medical management of patients with diabetes mellitus and stable coronary artery disease (CAD) is equivalent to revascularization in terms of morality benefit and rates of major adverse cardiovascular events, particularly in patients who do not have extensive CAD. Nonetheless, in those diabetic patients with additional high-risk features including left main disease, reduced left ventricular ejection fraction (LVEF), severe ischemia, or acute coronary syndrome, revascularization remains the best treatment option. Although the evidence still supports coronary artery bypass grafting (CABG) as the standard of care for revascularization of diabetic patients with multivessel CAD and/or reduced LVEF, percutaneous coronary intervention (PCI) with drug-eluting stents (DES) has resulted in at least partial closure of the gap in benefit between surgery and catheter-based intervention. Ongoing trials of diabetic patients with CAD randomized to PCI or CABG will help further elucidate the role of PCI with DES as a potential revascularization option for this patient population.

Microalbuminuria and Prediction of Cardiovascular Complications in Patients with Coronary Artery Disease and Type 2 Diabetes Mellitus after CABG Surgery

“…Chronic kidney disease was defined by the presence of certain kidney injury markers persisting during at least three months or more according to the Russian Guidelines on chronic kidney disease. These markers included: 1) renal structural lesions revealed by ultrasound investigation (abnormalities of renal development, hydronephrosis, kidney cysts, kidney stones); 2) albuminuria/proteinuria; 3) persistent erythrocyturia, cylindruria, leukocyturia; 4) persistent decrease of GFR less than 60 ml/min/1,73m 2 [11] that were assessed using medical histories. Morphological renal abnormalities included chronic pyelonephritis and kidney stones or cysts found by ultrasound investigation.…”

“…In recent years, there has been a trend towards an increasing incidence of coronary artery disease (CAD) along with type 2 diabetes mellitus (type 2 DM) [1]. The prognosis of CAD amongst patients with type 2 DM is significantly worse compared to other patients [2], and it does not depend on the type of heart surgery [3]. Prevalence of type 2 DM amongst patients with CAD who undergo coronary artery bypass graft (CABG) surgery varies from 19% to 30% and even to 40% [4,5].…”

The continued importance of optimal medical therapy with or without revascularization in diabetic patients with coronary artery disease

“…Over the past three decades, this fact has stimulated efforts to define which revascularization strategy represents the best approach in diabetic patients with stable ischemic heart disease (SIHD). The emphasis on revascularization has been based on the assumption that it is superior to optimal medical therapy (OMT) for reducing long-term cardiovascular events, improving quality of life, and other metrics such as long-term left ventricular systolic function [4][5][6].In this issue of the Journal, Razzouk and Farkouh [7] present a thoughtful and comprehensive review on the epidemiology and unique aspects of the pathophysiology of CAD in diabetic patients and provide an overall assessment of the scientific evidence base underlying which initial management approach (revascularization or OMT) is best suited for favorably influencing outcomes in this growing population of SIHD patients with T2DM. The authors appropriately recommend that lifestyle modification (including regular aerobic exercise, tobacco smoking cessation, weight loss, and adopting a healthy diet) should serve as the first-line intervention and foundation of SIHD management in diabetic patients.…”

“…Over the past three decades, this fact has stimulated efforts to define which revascularization strategy represents the best approach in diabetic patients with stable ischemic heart disease (SIHD). The emphasis on revascularization has been based on the assumption that it is superior to optimal medical therapy (OMT) for reducing long-term cardiovascular events, improving quality of life, and other metrics such as long-term left ventricular systolic function [4][5][6].…”