Coronary revascularisation in the patient with diabetes: balancing risk and benefit

The Bypass Angioplasty Revascularisation Investigation 2 Diabetes trial showed that patients with T2DM and mild or moderate CAD can be managed equally safely with intensive medical therapy alone until revascularisation becomes clinically indicated because of advancing coronary symptoms or a clinical scenario such as unstable angina, for which revascularisation is necessary. In patients with T2DM and severe CAD, BARI 2D showed that CABG with medical therapy was superior to initial medical therapy alone in reducing cardiovascular events. This is a major new finding as this is the first trial demonstrating the potential of CABG to reduce the risk of future non-fatal MI - something PCI could not provide when compared to initial medical therapy alone. Subgroup analysis of clinical trials, registry data and recently reported trials suggest that CABG is superior to PCI in patients with diabetes and multivessel disease, but the results of the FREEDOM trial might influence future decision-making.