Thrombotic/Thrombolytic Balance as a Cardiac Treatment Determinant in Patients With Diabetes Mellitus and Coronary Artery Disease

Background This study aimed to assess whether the plasminogen activator inhibitor-1/tissue plasminogen activator ( PAI -1/ tPA ) ratio as a prothrombotic state is useful for optimizing cardiac treatment strategy. Methods and Results Using BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial data, we used a Cox proportional hazard model to calculate hazard ratios with 95% CI s for cardiac events in patients receiving early revascularization (percutaneous coronary intervention or coronary artery bypass grafting) or medical therapy, separately in patients with low (n=1276) and high (n=894) PAI -1/ tPA ratios. The primary outcome was major cardiac events, which was a composite end point including cardiac death and nonfatal myocardial infarction. The mean± SD follow-up period was 4.1±1.7 years. The risk of major cardiac events in patients with high PAI -1/ tPA ratio was significantly higher when receiving percutaneous coronary intervention (hazard ratio, 1.84; 95% CI , 1.16-2.93; P=0.01) than when receiving medical therapy, whereas that in patients with low PAI -1/ tPA ratio did not differ significantly between the groups (hazard ratio, 0.95; 95% CI , 0.66-1.36; P=0.77); the interaction between the cardiac treatment strategy and PAI -1/ tPA ratio was significant ( P=0.02). However, regardless of the PAI -1/ tPA ratio, major cardiac event risk seemed to be lower in patients receiving coronary artery bypass grafting than in those receiving medical therapy. Conclusions In patients with type 2 diabetes mellitus and coronary artery disease, this study demonstrated that those with high PAI -1/ tPA ratio were at higher risks of major cardiac events when treated with percutaneous coronary intervention than when treated with intensive medical therapy.