(Circulation. 1996;93:1613-1615.)
© 1996 American Heart Association, Inc.
Articles |
Potentiation of Vasculopathy by Insulin
Implications From an NHLBI Clinical Alert
From the Medical Center Hospital of Vermont, Burlington.
Correspondence to Burton E. Sobel, MD, Department of Medicine, Medical Center Hospital of Vermont, Fletcher House 311, Burlington, VT 05401.
Key Words: Editorials • insulin • diabetes mellitus
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Introduction |
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Clinical alerts (safety bulletins) emanating from data monitoring and policy boards of large-scale clinical trials are both hallmarks and progenitors of progress. A recent clinical alert from the National Heart, Lung, and Blood Institute based on experience in the Bypass Angioplasty Revascularization Investigation (BARI) multicenter, international, randomized patient assignment trial is a cogent example.1 The trial compares two possible initial revascularization procedures for patients with multivessel coronary artery disease: (1) coronary artery bypass graft surgery (CABG) and (2) angioplasty (percutaneous transluminal coronary angioplasty [PTCA]). The observation that gave rise to the clinical alert was that for patients with type I or type II diabetes mellitus who were being treated with oral hypoglycemic agents or insulin, the 5-year mortality rate was 35% after initial revascularization with PTCA, significantly greater than the 19% mortality for patients treated with CABG, even though the angioplasties themselves were not unsuccessful or associated with undue complications. Mortality in both groups was considerably greater than the 9% mortality associated with PTCA and with CABG in nondiabetic patients and in diabetic patients not being treated with insulin or oral hypoglycemic agents. The clinical alert concluded that "BARI's results indicate that CABG should be the preferred treatment for patients with diabetes on drug or insulin therapy who have multivessel coronary artery disease and need a first coronary revascularization."1 The implications are intriguing.
The BARI observations imply that in patients with diabetes mellitus in
whom exogenous insulin is being given or in whom endogenous
insulin is high (in view of
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