Clinical and Angiographic Risk Stratification and Differential Impact on Treatment Outcomes in the BARI 2D Trial

Study Questions:

Do clinical or angiographic features predict benefit from revascularization in patients with diabetes and stable coronary artery disease?

Methods:

The authors assessed the difference in outcome of patients randomized to medical therapy versus revascularization based on their baseline clinical and angiographic risk. The angiographic risk score included myocardial jeopardy index, total number of coronary lesions, prior coronary revascularization, and left ventricular ejection fraction. The Framingham risk score for patients with coronary disease was used to summarize clinical risk.

Results:

There was no overall difference in outcome between patients randomized to medical therapy versus those randomized to revascularization across the entire risk profile. Among the highest angiographic risk tertile patients who were selected for coronary artery bypass grafting (CABG), the 5-year risk of death/myocardial infarction (MI)/stroke was lower in patients who were randomized to surgical revascularization (24.8% vs. 36.8% for those treated with medical therapy, p = 0.005). This benefit was further amplified in those who had both a high angiographic risk and a high Framingham risk (47.3% with medical therapy vs. 27.1%, p = 0.010; hazard ratio, 2.10; p = 0.009). Treatment group differences were not significant within any risk groups in the percutaneous coronary intervention stratum or in other clinical-angiographic risk groups within the CABG stratum.

Conclusions:

Among patients with diabetes and stable coronary artery disease, a strategy of prompt CABG significantly reduces the rate of death/MI/stroke in those with extensive coronary artery disease or impaired left ventricular function.

Perspective:

This interesting subgroup analysis suggests that the benefit of CABG in patients with stable coronary artery disease is restricted to patients with extensive coronary artery disease. The clinical application of the BARI 2D angiographic risk score may be premature since the discrimination was marginal (c-statistic of 0.63). However, the findings were derived in the setting of carefully supervised optimal medical therapy, and it is likely that the absolute benefit of CABG may be greater in routine clinical practice, where such stringent risk factor control may not be universal. CABG and medical therapy should remain the preferred strategy of choice in diabetic patients with extensive coronary artery disease.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease

Keywords: Stroke, Myocardial Infarction, Coronary Artery Disease, Risk Factors, Primary Prevention, Percutaneous Coronary Intervention, GTP Pyrophosphokinase, Cardiovascular Diseases, Atrial Fibrillation, Ventricular Function, Stroke Volume, Coronary Artery Bypass, Diabetes Mellitus


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