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(Circulation. 1999;99:847-851.)
© 1999 American Heart Association, Inc.
Editorial |
Importance of Considering Atherosclerosis Progression When Choosing a Coronary Revascularization Strategy
The Diabetes–Percutaneous Transluminal Coronary Angioplasty Dilemma
From the Beth Israel Deaconess Medical Center, Boston, Mass.
Correspondence to Richard E. Kuntz, MD, MSc, Cardiovascular Division, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215.
Key Words: Editorials • revascularization • diabetes mellitus • bypass • angioplasty
The choice of which
coronary revascularization strategy is best
for diabetic patients with multivessel coronary disease has
always been complex. The presence of diabetes, especially
insulin-requiring diabetes, has been associated with higher rates of
acute and late-term adverse events for both PTCA1 and
bypass surgery,2 making either approach seemingly
suboptimal. The results of the Bypass Angioplasty
Revascularization Investigation (BARI)
trial,3 however, strongly suggest that bypass surgery is
the treatment of choice over PTCA. High restenosis
rates,4 inability to fully revascularize all
ischemic territories,5 and progression of
atherosclerosis6 7 8 are generally cited as
the major problems that limit the effectiveness of
percutaneous coronary
revascularization (PCR) in diabetic patients. But
in everyday practice when patients are found to have clinical
ischemia and multivessel disease at coronary
angiography, the choice of revascularization
approach is often based largely on the feasibility of PCR, with little
regard for the presence or absence of diabetes. Is this decision-making
process wrong? Lack of finding a detrimental PTCA treatment effect for
diabetics in other randomized trials or large clinical
databases,2 9 10 limited clinical follow-up (
6 years)
that cannot measure the impact of probable late-term bypass vein graft
failure in patients who receive initial bypass surgery, and lack of
outcomes reflecting coronary stenting are generally cited as
the major factors that limit the notion that surgery is the treatment
of choice. Moreover, initial experiences with radiation
therapy11 and the glycoprotein IIb/IIIa
receptor blocker abciximab12 have shown promising
reduction in late loss within stents of diabetic patients and further
support the
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