Effect of prompt revascularization on outcomes in diabetic patients with stable ischemic heart disease and previous myocardial infarction in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial

BACKGROUND: Survivors of a myocardial infarction (MI) are at a considerable risk of developing further cardiovascular events, including recurrent MI, heart failure, stroke, and death. Patients with type 2 diabetes mellitus and stable ischemic heart disease (SIHD) have worse outcomes than their nondiabetic counterparts, and those with previous MI may be at particularly high risk. Yet, little is known about the effect of adding prompt revascularization to intensive medical therapy in this high-risk group. PATIENTS AND METHODS: We carried out a post-hoc analysis of the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial, which randomized patients with type 2 diabetes mellitus and SIHD to prompt revascularization with percutaneous coronary intervention or coronary artery bypass grafting in addition to intensive medical therapy or intensive medical therapy alone. Previous MI status was defined by a history of MI or pathologic Q-waves. The primary endpoints were death, nonfatal or fatal MI, nonfatal or fatal stroke, congestive heart failure, and a composite of death/MI/stroke. RESULTS: Of the 2280 patients with evaluable data, 936 had previous MI. In these patients, there were no differences in the 5-year event-free rates of all-cause death, MI, stroke, congestive heart failure, or death/MI/stroke between those who were randomized to prompt revascularization in addition to intensive medical therapy and those who were randomized to intensive medical therapy alone. CONCLUSION: In diabetic patients with SIHD and previous MI, adding prompt revascularization to intensive medical therapy yielded no benefit compared with intensive medical therapy alone. These findings underscore the importance of intensive medical therapy in mitigating further ischemic events.