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(Circulation. 1997;96:1761-1769.)
© 1997 American Heart Association, Inc.
Articles |
Influence of Diabetes on 5-Year Mortality and Morbidity in a Randomized Trial Comparing CABG and PTCA in Patients With Multivessel Disease
The Bypass Angioplasty Revascularization Investigation (BARI)
From the NHLBI, Bethesda, Md; the Graduate School of Public Health, University of Pittsburgh (Pa); and the BARI Investigative Sites.
Correspondence to Robert L. Frye, MD, University of Pittsburgh, 127 Parran Hall, 130 DeSoto St, Pittsburgh, PA 15261.
Background Patients with diabetes mellitus have increased morbidity and mortality after coronary revascularization. The Bypass Angioplasty Revascularization Investigation (BARI), a trial of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass graft surgery (CABG) in patients with multivessel disease, reported a 5-year survival advantage of CABG over PTCA in patients with treated diabetes mellitus (TDM). This report examines these findings in more detail.
Methods and Results Eighteen clinical centers randomly assigned 1829 patients with multivessel coronary disease to undergo initial CABG or PTCA. Patients were followed an average of 5.4 years. TDM was defined as a history of diabetes with use of oral hypoglycemic agents or insulin at study entry. Nineteen percent of the randomized population (353 patients) met these criteria. TDM patients had more unfavorable baseline characteristics than other patients, but among TDM patients, these characteristics were similar between the CABG and PTCA groups. Better average 5.4-year survival with CABG was due to reduced cardiac mortality (5.8% versus 20.6%, P=.0003), which was confined to those receiving at least one internal mammary artery graft.
Conclusions Patients with TDM assigned to an initial strategy of CABG have a striking reduction in cardiac mortality compared with PTCA. Long-term internal mammary artery graft patency may contribute to this improved outcome by reducing the fatality of follow-up myocardial infarction.
Key Words: angioplasty • bypass • coronary disease • diabetes mellitus • trials
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D. K. McGuire, K. J. Anstrom, and E. D. Peterson Influence of the Bypass Angioplasty Revascularization Investigation National Heart, Lung, and Blood Institute Diabetic Clinical Alert on Practice Patterns: Results from the National Cardiovascular Network Database Circulation, April 15, 2003; 107(14): 1864 - 1870. [Abstract] [Full Text] [PDF]
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F. B. Sozzi, A. Elhendy, J. R.T.C. Roelandt, R. T. van Domburg, A. F.L. Schinkel, E. C. Vourvouri, J. J. Bax, J. De Sutter, A. Borghetti, and D. Poldermans Prognostic Value of Dobutamine Stress Echocardiography in Patients With Diabetes Diabetes Care, April 1, 2003; 26(4): 1074 - 1078. [Abstract] [Full Text] [PDF]
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B. E. Sobel, R. Frye, and K. M. Detre Burgeoning Dilemmas in the Management of Diabetes and Cardiovascular Disease: Rationale for the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial Circulation, February 4, 2003; 107(4): 636 - 642. [Abstract] [Full Text] [PDF]
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A. D. Mooradian Cardiovascular Disease in Type 2 Diabetes Mellitus: Current Management Guidelines Arch Intern Med, January 13, 2003; 163(1): 33 - 40. [Abstract] [Full Text] [PDF]
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A. M. Calafiore, M. Di Mauro, G. Di Giammarco, M. Contini, G. Vitolla, A. Lorena Iaco, C. Canosa, and S. D'Alessandro Effect of diabetes on early and late survival after isolated first coronary bypass surgery in multivessel disease J. Thorac. Cardiovasc. Surg., January 1, 2003; 125(1): 144 - 154. [Abstract] [Full Text] [PDF]
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M. Laakso and J. Kuusisto Diabetology for cardiologists Eur. Heart J. Suppl., January 1, 2003; 5(suppl_B): B5 - B13. [Abstract] [PDF]
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L. Schwartz, K. E. Kip, R. L. Frye, E. L. Alderman, H. V. Schaff, and K. M. Detre Coronary Bypass Graft Patency in Patients With Diabetes in the Bypass Angioplasty Revascularization Investigation (BARI) Circulation, November 19, 2002; 106(21): 2652 - 2658. [Abstract] [Full Text] [PDF]
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 P.-G. Chassot, A. Delabays, and D. R. Spahn Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery Br. J. Anaesth., November 1, 2002; 89(5): 747 - 759. [Abstract] [Full Text] [PDF]
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P.G. Steg and L.J. Feldman Percutaneous coronary intervention in diabetics with prior coronary artery bypass surgery: sweet or sour? Eur. Heart J., September 2, 2002; 23(18): 1411 - 1412. [Full Text] [PDF]
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P F Ludman Percutaneous coronary intervention in diabetics: time to consider "intimal remodelling therapy"? Heart, September 1, 2002; 88(3): 213 - 215. [Full Text] [PDF]
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E. Van Belle, M. Perie, D. Braune, A. Chmait, T. Meurice, K. Abolmaali, E. P. McFadden, C. Bauters, J.-M. Lablanche, and M. E. Bertrand effects of coronary stenting on vessel patency and long-term clinical outcome after percutaneous coronary revascularization in diabetic patients J. Am. Coll. Cardiol., August 7, 2002; 40(3): 410 - 417. [Abstract] [Full Text] [PDF]
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V. Mathew and D. R. Holmes Outcomes in diabetics undergoing revascularization: The long and the short of it J. Am. Coll. Cardiol., August 7, 2002; 40(3): 424 - 427. [Full Text] [PDF]
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L. Gruberg, R. Waksman, A. E. Ajani, H.-S. Kim, R. L. White, E. E. Pinnow, L. F. Satler, A. D. Pichard, K. M. Kent, and J. Lindsay Jr The effect of intracoronary radiation for the treatment of recurrent in-stent restenosis in patients with diabetes mellitus J. Am. Coll. Cardiol., June 19, 2002; 39(12): 1930 - 1936. [Abstract] [Full Text] [PDF]
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J. A. Beckman, M. A. Creager, and P. Libby Diabetes and Atherosclerosis: Epidemiology, Pathophysiology, and Management JAMA, May 15, 2002; 287(19): 2570 - 2581. [Abstract] [Full Text] [PDF]
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S. C. Smith Jr, D. Faxon, W. Cascio, H. Schaff, T. Gardner, A. Jacobs, S. Nissen, and R. Stouffer Prevention Conference VI: Diabetes and Cardiovascular Disease: Writing Group VI: Revascularization in Diabetic Patients Circulation, May 7, 2002; 105 (18): e165 - e169. [Full Text] [PDF]
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T. J. Vander Salm, K. E. Kip, R. H. Jones, H. V. Schaff, R. J. Shemin, G. S. Aldea, and K. M. Detre What constitutes optimal surgical revascularization?: Answers from the bypass angioplasty revascularization investigation (BARI) J. Am. Coll. Cardiol., February 20, 2002; 39(4): 565 - 572. [Abstract] [Full Text] [PDF]
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T. Hirotani, S. Shirota, Y. Cho, and S. Takeuchi Feasibility and suitability of the routine use of bilateral internal thoracic arteries Ann. Thorac. Surg., February 1, 2002; 73(2): 511 - 515. [Abstract] [Full Text] [PDF]
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E. Erdmann Cardiovascular events in patients with type 2 diabetes The British Journal of Diabetes & Vascular Disease, January 1, 2002; 2(1_suppl): S4 - S8. [Abstract] [PDF]
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K. M. Detre and R. Holubkov Coronary Revascularization on Balance: Robert L. Frye Lecture Mayo Clin. Proc., January 1, 2002; 77(1): 72 - 82. [Abstract] [PDF]
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S. Giri, L. J. Shaw, D. R. Murthy, M. I. Travin, D. D. Miller, R. Hachamovitch, S. Borges-Neto, D. S. Berman, D. D. Waters, and G. V. Heller Impact of Diabetes on the Risk Stratification Using Stress Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging in Patients With Symptoms Suggestive of Coronary Artery Disease Circulation, January 1, 2002; 105(1): 32 - 40. [Abstract] [Full Text] [PDF]
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 P. J. Pugh, L. O'Toole, K. S. Channer, D. P. Taggart, A. Banning, K. Channon, M. J. Mack, M. Murtaza, M. Singh, L. Dharmarajan, et al. Coronary-Artery Bypass Surgery versus Stenting for Multivessel Disease N. Engl. J. Med., November 29, 2001; 345(22): 1641 - 1643. [Full Text] [PDF]
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S. D. Fihn, S. V. Williams, J. Daley, and R. J. Gibbons Guidelines for the Management of Patients with Chronic Stable Angina: Treatment Ann Intern Med, October 16, 2001; 135(8_Part_1): 616 - 632. [Abstract] [Full Text] [PDF]
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A. M. Calafiore, M. Di Mauro, M. Contini, G. Di Giammarco, M. Pano, G. Vitolla, A. Bivona, R. Carella, and S. D'Alessandro Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome Ann. Thorac. Surg., August 1, 2001; 72(2): 456 - 462. [Abstract] [Full Text] [PDF]
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A. Abizaid, M. A. Costa, M. Centemero, A. S. Abizaid, V. M.G. Legrand, R. V. Limet, G. Schuler, F. W. Mohr, W. Lindeboom, A. G.M.R. Sousa, et al. Clinical and Economic Impact of Diabetes Mellitus on Percutaneous and Surgical Treatment of Multivessel Coronary Disease Patients: Insights From the Arterial Revascularization Therapy Study (ARTS) Trial Circulation, July 31, 2001; 104(5): 533 - 538. [Abstract] [Full Text] [PDF]
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S. C. Smith Jr, J. T. Dove, A. K. Jacobs, J. Ward Kennedy, D. Kereiakes, M. J. Kern, R. E. Kuntz, J. J. Popma, H. V. Schaff, D. O. Williams, et al. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines): A report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines (Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions J. Am. Coll. Cardiol., June 15, 2001; 37(8): 2239 - 2239. [Full Text] [PDF]
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A. Elhendy, A. M. Arruda, D. W. Mahoney, and P. A. Pellikka Prognostic stratification of diabetic patients by exercise echocardiography J. Am. Coll. Cardiol., May 1, 2001; 37(6): 1551 - 1557. [Abstract] [Full Text] [PDF]
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K. J. Mather, S. Verma, and T. J. Anderson Improved endothelial function with metformin in type 2 diabetes mellitus J. Am. Coll. Cardiol., April 1, 2001; 37(5): 1344 - 1350. [Abstract] [Full Text] [PDF]
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N. W. Niles, P. D. McGrath, D. Malenka, H. Quinton, D. Wennberg, S. J. Shubrooks, J. F. Tryzelaar, R. Clough, M. J. Hearne, F. Hernandez Jr, et al. Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study J. Am. Coll. Cardiol., March 15, 2001; 37(4): 1008 - 1015. [Abstract] [Full Text] [PDF]
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E. Van Belle, R. Ketelers, C. Bauters, M. Perie, K. Abolmaali, F. Richard, J.-M. Lablanche, E. P. McFadden, and M. E. Bertrand Patency of Percutaneous Transluminal Coronary Angioplasty Sites at 6-Month Angiographic Follow-Up : A Key Determinant of Survival in Diabetics After Coronary Balloon Angioplasty Circulation, March 6, 2001; 103(9): 1218 - 1224. [Abstract] [Full Text] [PDF]
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R. J. Gibbons, D. D. Miller, P. Liu, P. Guo, M. M. Brooks, and M. Schwaiger Similarity of Ventricular Function in Patients Alive 5 Years After Randomization to Surgery or Angioplasty in the BARI Trial Circulation, February 27, 2001; 103(8): 1076 - 1082. [Abstract] [Full Text] [PDF]
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W. A. Hsueh, S. Jackson, and R. E. Law Control of Vascular Cell Proliferation and Migration by PPAR-{gamma}: A new approach to the macrovascular complications of diabetes Diabetes Care, February 1, 2001; 24(2): 392 - 397. [Abstract] [Full Text]
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