This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Investigators, T. B. Search for Related Content PubMed PubMed Citation Articles by Investigators, T. B.

(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)

The BARI Investigators¹

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.

	Abstract

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
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

	Introduction

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
Patients with diabetes mellitus have a greater incidence of atherosclerotic cardiovascular disease, which, when present, is associated with increased mortality and morbidity compared with nondiabetic patients with cardiovascular disease.^{1 2 3 4 5 6} Diabetes is an independent risk factor for lesion progression, graft occlusion, and cardiac mortality after CABG.^{7 8 9 10 11} In two recent studies, a history of diabetes was associated with a twofold increase in mortality over 5 to 8 years after PTCA compared with patients without diabetes.^{12 13} In addition, diabetes mellitus has been identified as an independent risk factor for the development of restenosis after balloon angioplasty or stent placement.^{14 15}

In 1987, the NHLBI initiated the BARI, a randomized trial to compare the efficacy of CABG and PTCA in patients with multivessel disease.^{16 17 18 19 20} The primary hypothesis was that an initial revascularization strategy of PTCA did not compromise clinical outcome over a 5-year period compared with an initial strategy of CABG. BARI recently reported no significant difference in survival over a 5-year period between the two strategies.²¹ Four baseline patient characteristics (clinical presentation, number of coronary vessels diseased, left ventricular function, and American College of Cardiology/American Heart Association lesion type) were prespecified for subgroup analysis. On the basis of findings of an earlier trial,²² the Safety and Data Monitoring Board recommended that diabetes also be monitored. Among patients with TDM, defined as diabetes mellitus treated with oral hypoglycemic agents or insulin at study entry, all-cause mortality was significantly lower in those assigned to CABG than in those assigned to PTCA (19% versus 35%, P=.003).²¹ The present report extends this comparison to cause-specific mortality and examines CABG efficacy by use of IMA grafts versus SVGs only.

	Methods

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
The trial protocol, including a detailed description of study aims, patient selection, exclusion criteria, procedure guidelines, definitions, and administrative structure, has been published.^{16 17 18 19 20} Briefly, patients were eligible for BARI if they had angiographically documented multivessel coronary artery disease with either clinically severe angina or objective evidence of marked myocardial ischemia requiring revascularization and were suitable for both PTCA and CABG. Between August 1988 and August 1991, 1829 patients from 18 clinical centers were entered into the trial after providing written informed consent. Patients were followed an average 5.4 years, until June 5, 1995, when 67% had 5 years of follow-up. The primary study end point was all-cause mortality at 5 years. Secondary end points included MI and functional and symptomatic status.

Cause of Death
Cause of death was classified by an independent Mortality and Morbidity Classification Committee as cardiac, noncardiac but related to atherosclerotic disease, other noncardiac medical causes (eg, cancer, pulmonary disease), trauma, suicide, and other or unknown causes.¹⁶ Cardiac death was defined as death <1 hour after onset of cardiac symptoms, within 30 days after documented or probable MI, or due to intractable CHF, cardiogenic shock, or other documented cardiac causes. A cardiac cause was defined as contributory when cardiac malfunction was involved but other direct causes of death could not be ruled out (eg, chronic CHF with pulmonary embolism). Documents used for classification included death certificate; coroner's report if available; report from the clinical center's principal investigator; surgical and catheterization laboratory reports if death occurred within 30 days of a procedure; ECG and enzyme data if measured within 24 hours of death; and the patient's baseline, procedure, and hospital study data. Each case was reviewed independently by two committee members, with disagreements resolved by full committee consensus.

Myocardial Infarction
Q-wave MI was determined by central laboratory analysis of ECGs requiring a two-step worsening of the Minnesota Q-wave code^{23 24} or a new left bundle-branch block associated with a twofold increase in total creatine phosphokinase with a positive MB fraction. Non–Q-wave MI was diagnosed when cardiac enzymes were elevated with chest pain for >20 minutes or with the appearance of new ECG changes. Cardiac enzymes were not used to define an MI within 96 hours after coronary revascularization.

Initial Revascularization Procedures
Left ventricular and coronary arteriographic findings were analyzed by a central laboratory using a quantitative arteriographic coding system.²⁵ A successful dilatation was defined as (1) reduction in luminal diameter narrowing of 20%, (2) final lumen diameter narrowing of <50%, and (3) TIMI grade 3 flow. The details of surgical revascularization were collected prospectively.

Statistical Methods
Patient group differences were evaluated with the ² test (or Fisher's exact test) for categorical data and the Wilcoxon test for continuous or count data. Crude cause-specific mortality rates for an average 5.4 years of follow-up were computed as a percentage of the number of patients at baseline. The Kaplan-Meier estimate²⁶ was used to calculate cardiac survival (freedom from cardiac mortality) under the assumption that censoring for incomplete follow-up or noncardiac death was noninformative. The log-rank statistic, stratified according to clinical center, was used to compare cardiac survival curves between treatment groups. A Cox regression model²⁷ was used to compare cardiac mortality rates, adjusted for baseline differences, in patients with TDM after PTCA, after CABG with an IMA graft, and after all other CABG procedures (SVG only). In the Cox model, baseline differences between the three treatment groups were summarized by a score that estimated each patient's likelihood of receiving an IMA graft. The score function was obtained from a logistic regression model using symptomatic and ischemic status, race, sex, age 65 years, right-dominant coronary artery system, four or more significant lesions, significant lesion in the left anterior descending coronary artery, CHF, and body mass index to predict which CABG patients received an IMA graft. To assess the influence of MI on mortality, cardiac mortality rates were computed for patients with a diagnosed MI and for those without a diagnosed MI in each of three groups (PTCA, CABG with IMA, and CABG with SVG only).

	Results

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
At study entry, 447 patients (24% of the randomized population) had a history of diabetes and 353 (19%) had TDM as defined above. The 94 patients with a history of diabetes but not receiving oral hypoglycemic agents or insulin were included in the 1476 patients classified as not having TDM or "all other" BARI patients.

Baseline Characteristics
BARI patients with and without TDM differed substantially (Table 1). Patients with TDM were more often women and blacks and had a lower formal educational level than other patients. A higher proportion of those with TDM had a history of CHF, hypertension, chronic renal failure, and peripheral vascular disease. In addition, TDM patients had higher triglyceride levels and body mass indexes. The severity of angina at the time of randomization was similar, but TDM patients were more likely to report an inactive lifestyle and a lower quality of life. The extent of coronary disease was also greater in the TDM group, as reflected by the presence of three-vessel disease and more distal lesions. Left ventricular ejection fraction was lower among treated diabetics.

View this table: [in this window] [in a new window]   Table 1. Baseline Characteristics

Among TDM patients, baseline characteristics were equally distributed between treatment arms, with the exception that PTCA patients had higher mean LDL cholesterol.

Initial Revascularization Procedure
Table 2 presents characteristics of the initial intervention for patients receiving their assigned treatment. For patients assigned to CABG with and without TDM, 96% and 98%, respectively, received their assigned procedures. TDM patients had a higher mean number of significant lesions and distal sites and a lower proportion with all intended vessels grafted. IMA grafting, whose use (81% to 82% of all CABGs) did not differ by TDM status, was usually performed in conjunction with SVGs. There was a greater use of sequential grafts in the TDM patients.

View this table: [in this window] [in a new window]   Table 2. Characteristics of the Initial CABG and PTCA

For patients assigned to PTCA, 98% with TDM and 95% without TDM underwent their assigned procedure. TDM patients had more significant stenoses and more distal lesions but a similar number of attempted lesions (2.4 versus 2.3). Among significant attempted lesions, TDM patients had a lower mean reference diameter before and after PTCA, as well as lower mean minimum lumen diameter after PTCA (P<.01 for each comparison).

In-Hospital Events
Within each treatment arm, in-hospital event rates were similar among patients with and without TDM (Table 3). Among those with TDM, the in-hospital mortality was 1.2% for CABG and 0.6% for PTCA, and the incidence of Q-wave MI was threefold greater after CABG compared with PTCA. Among the TDM patients receiving PTCA, 7.1% required emergency CABG and 2.9% underwent nonemergency CABG during the initial hospitalization, and 2.4% required emergency PTCA. Other minor complications were similar between the CABG and PTCA groups.

View this table: [in this window] [in a new window]   Table 3. Procedure Complications

All-Cause Mortality During Follow-up
The 5-year survival of TDM patients was significantly worse than for other patients (73.1% versus 91.3%, P<.0001 for the log-rank test). For the 94 patients with untreated diabetes at baseline, the 5-year survival was 93.3% compared with 91.1% for the 1382 patients without a history of diabetes. When the patients with TDM were analyzed by treatment assignment, the cumulative survival rates were significantly higher for patients assigned to CABG on the basis of a stringent prespecified .005 level of significance (80.6 for CABG, 65.5 for PTCA, P=.003 for the log-rank test). This treatment difference did not vary significantly by clinical centers (P=.90).

Cause-Specific Mortality
Cause-specific mortality after an average of 5.4 years of follow-up is shown in Table 4 for patients who underwent their assigned revascularization procedure. Cardiac mortality rates were 20.6% and 5.8% for PTCA and CABG, respectively, among patients with TDM, compared with 4.8% and 4.7%, respectively, for other BARI patients. Rates of noncardiac death related to atherosclerosis and of death attributed to other medical causes, while considerably higher for patients with TDM, were comparable by assigned treatment within both TDM and non-TDM patients. Thus, among patients with TDM, the excess mortality observed in the PTCA group in comparison with the CABG group was cardiac and not due to other causes (P<.01 by Fisher's exact test). As seen in the Figure, the cardiac survival curves between TDM and non-TDM patients diverge steadily beginning in the first year of follow-up, as do the survival curves within the TDM group by assigned treatment.

View this table: [in this window] [in a new window]   Table 4. Cause-Specific Mortality Rates

View larger version (13K): [in this window] [in a new window]   Figure 1. Cardiac survival after assignment to PTCA and CABG in 353 patients with TDM and in 1476 patients without TDM.

Impact of IMA Use on Cardiac Events
The relation of the presence of an IMA graft to cardiac mortality was particularly striking (Table 5). Cardiac mortality with TDM was 2.9% when at least one IMA was used and 18.2% when only SVG conduits were used. The latter rate was similar to that of patients receiving PTCA (20.6%). Because patients were not assigned at random to use of IMA graft, this survival advantage could potentially be due to factors related to patient suitability for IMA grafts rather than the conduit itself. However, after adjustment for the selection factors (likelihood of receiving IMA grafts), cardiac mortality in TDM patients not treated with IMA grafts remained excessive, with an 8.1 risk ratio for cardiac death with PTCA and a 7.4 risk ratio for SVG alone compared with patients receiving at least one IMA graft (P<.005 for each comparison). Among patients without TDM, cardiac mortality rates were similar across the three treatment groups.

View this table: [in this window] [in a new window]   Table 5. Cardiac Death and Postrandomization MI

Postrandomization MI rates were also analyzed among TDM patients. Although the cardiac death rate in those receiving IMA grafts was substantially reduced compared with the other two groups, postrandomization MI rates were comparable for all three groups. However, when cardiac mortality and MI are cross-classified in the final two columns of Table 5, however, it is apparent that IMA use in diabetic patients was associated with sharply decreased cardiac mortality with or without MI.

Patients without TDM had nearly identical cardiac mortality and MI rates regardless of treatment or conduit. However, IMA use was once again associated with lower post-MI cardiac mortality. This finding in both nondiabetics and TDM patients suggests that an IMA graft protected patients from high cardiac mortality when an intervening MI was sustained. In the large majority of patients without TDM and without intercurrent MI, cardiac mortality was remarkably similar between CABG and PTCA.

	Discussion

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
The BARI Investigators recently reported that patients with TDM at the time of randomization to an initial strategy of PTCA experienced higher mortality over a period of 5 years compared with treated diabetics assigned to CABG.²¹ To elucidate the mechanisms potentially involved in this observed differential mortality, this report details clinical and angiographic characteristics and specific causes of death of patients with and without TDM.

The hazards of subgroup analysis without a priori defined hypotheses and sufficient sample size to achieve the desired power are well recognized, as is the influence of multiple analyses of the data. We established wide, 99.5% CIs for within-subgroup treatment comparisons, corresponding to a stringent .005 level of significance. Additional support for our findings comes from a recent report from another large multicenter randomized trial, the Coronary Angioplasty versus Bypass Revascularization Investigation (CABRI).²⁸ In contrast, the Emory Angioplasty versus Surgery Trial (EAST) failed to show a survival advantage for CABG.²⁹ The survival rate in the small group of diabetic patients in that study, however, was uncharacteristically similar to the nondiabetic patients.

Investigation of cause-specific mortality rates was critical to our understanding of the significant mortality difference observed between treatment groups in TDM patients. Cardiac mortality was more than three times higher in TDM patients initially revascularized with PTCA, whereas other cause-specific noncardiac death rates, although higher in TDM patients, remained remarkably similar by treatment group. Although patients with TDM are known to have a significantly higher incidence of restenosis and progression of coronary artery disease,^{1 2 3 4 5 6 7 8 9 10 11 12 13 14 15} we hypothesize that PTCA, rather than leading to increased mortality, may simply fail to alter the natural clinical course in TDM patients with coronary artery disease.

The survival benefit of CABG was limited to use of IMA grafts, and it was particularly striking after postrandomization MI in patients with and without TDM. Although postrandomization MI rates were comparable by assigned treatment and conduit type, the subsequent cardiac mortality was lowest with the placement of IMA grafts. This observation was similar to the substantially lower postinfarction mortality rates reported by Peduzzi et al³⁰ and Alderman³¹ in the VA study for patients initially randomized to CABG instead of medical treatment. We hypothesize that IMA grafts, being less susceptible to disease progression (accelerated in TDM), may provide better alternative sources of perfusion to maintain ventricular function in regions of hypoperfusion resulting from coronary occlusion.

It is well documented that diabetic patients have a greater incidence of mortality post-MI than nondiabetic patients.^{32 33 34 35 36 37 38} Among diabetic patients, MIs can more often be painless or atypical, manifesting and diagnosed as sudden CHF, cardiac shock, arrhythmia, or sudden death.^{39 40} Several basic mechanisms might explain the increased mortality of acute MI in diabetics. The benefits of preconditioning of the myocardium may be inhibited by the influence of hypoglycemic drugs that inhibit the ATPase-sensitive potassium channels.⁴¹ A hyperpolarizing mechanism present in endothelial cells of normal arteries may be impaired in diabetics, which may compromise endothelial cell function.⁴² Insulin resistance may contribute to abnormalities in coronary flow.⁴³ Microvascular abnormalities may lead to myocardial ischemia in diabetics even without epicardial coronary artery disease.⁴⁴ A higher incidence of silent ischemia, plaque disruption, and thrombosis in diabetic patients may help explain the increased rate of acute coronary syndromes and MI observed in diabetics.^{35 36 37 38 39 40 41 42 43 44 45} Diabetics have a higher incidence of lipid abnormalities and hypertension, which further increases their risk for coronary artery disease.^{1 2 3 4 5 6 7 8 9 10 11 12 13 14 15}

The results of two recent prospective studies have clearly documented the importance of glycemic control in reducing cardiovascular mortality and morbidity in diabetics.^{46 47} One-year mortality was also reduced in a randomized trial of diabetics with aggressive insulin and glucose therapy early after MI.⁴⁸ It has been estimated that in diabetic men, aggressive medical therapy and risk factor modification could reduce mortality from coronary artery disease, which is between three and five times greater than among nondiabetics.⁴⁹ The importance of control of diabetes cannot be overemphasized.

Limitations and Clinical Implications of the Study
The number of BARI patients with TDM was relatively small (353), although larger than in other recently reported trials comparing CABG and PTCA.^{28 29} Because diabetes was not the original focus of the BARI trial, we collected no detailed information as to the type, degree, and duration of diabetes. The BARI diabetic classification, also used in the diabetes substudy of the MRFIT trial and the Joslin Clinic follow-up study,^{6 32} was based on patient history, strengthened by the objective evidence of insulin or oral hypoglycemic use. Because BARI was not specifically designed to evaluate TDM, the adequacy of glucose control is unknown, and differential adherence to medical therapy cannot be ruled out.

The results for diabetic patients in BARI do not necessarily apply to all patients with diabetes. Treated diabetics in the BARI Registry who refused randomization were selected for treatment with PTCA without apparent compromise in survival compared with CABG.⁵⁰ These patients, however, do not share the adverse baseline characteristics of those in the randomized trial. This observation suggests that in certain diabetic patients, angioplasty may be a suitable alternative to bypass surgery. In addition, we did not enroll patients with single-vessel disease, and use of the IMA graft was left to the discretion of the operator rather than assigned at random. Interpretation of BARI results must also take into account the fact that the initial procedure was standard balloon angioplasty. The impact on outcomes among treated diabetics is not known for the new revascularization technologies, including the frequent use of stents.^{51 52 53}

The clinical implications of our observations are several. Among TDM patients with the characteristics of those randomized in BARI, CABG with IMA grafts appears to be the preferred initial treatment strategy. However, if only SVGs are used, cardiac mortality is similar to that with PTCA. The advances in catheter-based techniques, surgery, and medical therapy call for further properly controlled randomized clinical trials to determine the best treatment strategy for patients with diabetes mellitus.

	Selected Abbreviations and Acronyms

 

BARI = Bypass Angioplasty Revascularization Investigation CABG = coronary artery bypass graft surgery CHF = congestive heart failure IMA = internal mammary artery MI = myocardial infarction PTCA = percutaneous transluminal coronary angioplasty SVG = saphenous vein graft TDM = treated diabetes mellitus

	Acknowledgments

 
This study was sponsored by the National Heart, Lung, and Blood Institute.

	Footnotes

 
¹ Members of the Writing Group are given in the "Appendix."

	Appendix 1

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
Writing Group
This article was prepared by Edwin Alderman, MD, Martial Bourassa, MD, Maria M. Brooks, PhD, Robert Califf, MD, Bernard Chaitman, MD, Katherine Detre, MD, DrPH, David P. Faxon, MD, Frederick Feit, MD, Robert L. Frye, MD, Regina M. Hardison, BS, David Holmes, MD, Richard Holubkov, PhD, Nicholas Kouchoukos, MD, Ronald Krone, MD, William Rogers, MD, Allan D. Rosen, MS, Hartzell Schaff, MD, Leonard Schwartz, MD, Andrea S. Siewers, MPH, George Sopko, MD, MPH, Kim Sutton-Tyrrell, DrPH, and Patrick Whitlow, MD, on behalf of the BARI Investigators. Dr Frye, as study chairman, assumes responsibility for overall content and integrity of this article.

Participants in the BARI Trial
University of Alabama

Principal Investigator: W.J. Rogers. W.A. Baxley, L.S. Dean, G.S. Roubin, J.K. Kirklin, J.W. Kirklin, A. Pacifico, G.L. Zorn, E. Charles, T.D. Paine, S. Brewer, L.C. Carr, G. Duke, L.E. Maske, T.E. Morgan, K. Doss, J.A. Trobaugh, K.W. Anderson, M. Brunner-Scott, D. Bunn, F. Harris. Former participants: T. Bulle, J.B. Cavender, P.J. Garrahy.

Brown University: Rhode Island Hospital

Principal Investigator: D.O. Williams. T.M. Drew, A.K. Singh, G.N. Cooper, B.L. Sharaf, J.L. Wheeler. Former participants: M.E. Grogan, M. Macedo, J. Moran, E.S. Thomas, H. White.

Bellevue Hospital (Satellite to Brown)

Principal Investigators: F. Feit, M.J. Attubato. S.B. Colvin, A.C. Galloway, G. Ribakove, P.F. Pasternack, M. Rey, S. Shapiro.

Boston University

Principal Investigators: A.K. Jacobs, D.P. Faxon. G.R. Garber, N.A. Ruocco, R.S. Shemin, G.S. Aldea, T.J. Ryan, D.A. Weiner, B.R. Hankin, M.E. Mazur. Former participants: J.W. Currier, R.M. Mills, G. Paone, J.E. Brush, J.D. Fonger, M.A. Bettmann, J.A. Rothendler.

Cleveland Clinic Foundation

Principal Investigator: P.L. Whitlow. S. Ellis, I. Franco, R. Raymond, E. Topol, D. Cosgrove, F. Loop, B. Lytle, R. Stewart, P.C. Taylor, A.P. Dimas, A.M. Lincoff, W. Proudfit, G. Williams, M. Lowrie, K. Comella. Former participants: J. Frierson, F. Grigera, B. Healy, J. Hollman, L. Korcuska, B. Robalino, A. Rogers, S. Senick, J. Tedrick, K. Vaska.

Duke University

Principal Investigator: R.M. Califf. R.P. Bauman, V.S. Behar, Y. Kong, M.W. Krucoff, K.G. Morris, R.H. Peter, H.R. Phillips, R. Stack, J.E. Tcheng, R.H. Jones, H.N. Oldham, P. Van Tright, W.A. Baker, T. Bashore, D.F. Fortin, K. Lee, E.M. Ohman, L.A. Drew, M.A. Sellers, V.C. Bass. Former participants: B. Bacon, S.G. Burks, S. Caminiti, T. Daniels, D.J. Frid, H. Gessner, E. Hampton, M.J. Miller, D.B. Pryor, P.J. Quigley, J.S. Rankin, J. Richard, L. Santoro, A. N. Tenaglia.

Harvard University: Beth Israel Hospital

Principal Investigator: D. S. Baim. J. Aroesty, B. Lorell, R. Johnson, R. Thurer, R. Weintraub, M. Flatley. Former participants: M. Cunnion, T. DeFeo-Fraulini, D. Diver, R. McKay, C. McCabe, K. Miller, R. Safian, A. Slater.

Maine Medical Center (Satellite to Harvard)

Principal Investigator: M.A. Kellett Jr. W.D. Alpern, R.A. Anderson, D.J. Cutler, P.W. Sweeney, D.J. Donegan, S. Katz, R.S. Kramer, C.A. Lutes, J.R. Morton, E.R. Nowicki, J.F. Tryzelaar, R.L. White, C.T. Lambrew, S. Bosworth-Farrell, J.C. Kane, N. Tooker.

University of Massachusetts

Principal Investigator: B.H. Weiner. J. Moran, O.N. Okike, A. Pezzella, T.J. VanderSalm, M. Borbone, K. Quist. Former participants: J. Benotti, D. Bitran, J. Dalen, J. Gaca, J. Leppo, M. Pasque, M. Shay, P. Wanta, T. Wisnewski.

Mayo Clinic

Principal Investigator: M. Mock. J. Bresnahan, D. Holmes, G.S. Reeder, C. Mullany, T.A. Orszulak, H. Schaff, P.B. Berger, R. Gibbons, S.L. Kopecky, R.S. Schwartz, H.C. Smith, S. Matheson, L. Kelly, L.A. Pierre. Former participants: D. Bresnahan, B. Gersh, F. Nobrega, M. Peterson, R. Vlietstra.

Medical College of Virginia

Principal Investigator: M.J. Cowley. G. Vetrovec, A. Guerraty, D. Salter, A. Wechsler, K. Kelly Hall. Former participants: C.W. Crandall, D. DeBottis, G. DiSciascio, R.R. Lower, A. Maziarz, A. Nath, B. Sechrist, S. Szentpetery.

University of Michigan

Principal Investigator: B. Pitt. E. Bates, D. Muller, S. Bolling, M. Deeb, M. Kirsh, M.M. Stock, J. Corbett, P. Fox, T. Johnson, K. McNeely, S. Pitt. Former participants: L. Belzowski, D. Bondie, K. Burek, S. Ellis, L. Lee, D. Scarpace, M. Schwaiger, H. Shu, M. Stirling, P. Thomasma, E.J. Topol, J. Walton, S. Werns.

Montreal Heart Institute

Principal Investigator: M.G. Bourassa. R. Bonan, G. Cote, J. Crepeau, P. DeGuise, Y. Leclerc, C. Pelletier, J. Gregoire, G. Hudon, J. Lesperance, J. Trudel, C. Faille. Former participants: A. Arseneault, Y. Castonguay, H. Flageol, D.D. Waters, L. Whittom.

Toronto Hospital (Satellite to Montreal)

Principal Investigator: L. Schwartz. H. Aldridge, D. Uden, T. David, C. Feindel, B. Goldman, I. Lipton, L. Mickleborough, R. Weisel, D. Almond, C. Lazzam, M. McLoughlin, L. Zelovitsky, P. Liu, L. Lazzam, K. Mackie.

New York Medical College

Principal Investigator: M.B. Weiss. R. Moggio, R. Pooley, G. Reed, M. Sarabu, R. Steinberg. Former participants: D. Efstathakis, P. Praeger, M.V. Herman, K. Ryman, Y. Sait, E. Somberg, J.H. Stein.

St Louis University

Principal Investigator: B.R. Chaitman. F.V. Aguirre, M.J. Kern, G. Kaiser, V. Willman, R. Wiens, C. Huffman, T. Stonner, S. Aubuchon, M. Kramer. Former participants: H. Barner, U. Deligonul, J.Fehl, K. Galan, B. Poole, M.G. Vandormael.

Jewish Hospital (Satellite to St Louis)

Principal Investigators: R.J. Krone, N. Kouchoukos. A. Salimi, T.H. Wareing, P. Cole, K. Fischer, R. Kleiger, S. Kovacs, M. Rich, A. Shah, J. Humphrey, C. Benson, D. Bowen, G. Eisenkramer, T. Jones, E. Kelly, L. Kendricks, J. Moore, P. Rice, R. Umstead, J. Waldschmidt, B. Walker, J. Weaver. Former participants: M. Caruso, L. Coulter, L. Spinner.

Parallel Study

Institute of Clinical and Experimental Medicine, Prague, Czech Republic

Principal Investigator: V. Stank. A. Belán, J. Ková, P. Firt, J. Pirk, V. Koandrle, M. elízko, R. Jandová, E. Tchernoster.

Former Site

Georgetown University

Principal Investigator: K. Kent. N.M. Katz, R. Wallace, L. Elliott, C. Green, J. Lavelle, C. Rackely, K. Kelly Hall. Former participant: B. Shriver.

Central ECG and Myocardial Infarction Classification Laboratory

St Louis University Medical Center

Principal Investigator: B.R. Chaitman. P. Bjerregaard, I. Gussak, R.D. Wiens, L.T. Younis, K. Stocke, K. Russell, S. Cannon, C. Homeyer, M. Miller. Former participants: D. Kargl, L. Maitus, L. Shaw, B. Takase, A. Terry, S. Zhou.

Central Radiographic Laboratory

Stanford University Medical Center

Principal Investigator: E.L. Alderman. B. Brown, W. Sanders, L. Wexler, B. Hollak. Former participants: T. Beam, R. Moore, G. Shao-Zhou, M. Stadius.

Ancillary Study

Study of Economics and Quality of Life

Stanford University School of Medicine (SEQOL)

Principal Investigator: M. Hlatky. C. Winston, D. Boothroyd, I. Johnstone. Former participants: C. Bacon, K. Cavanaugh, N. Clapp-Channing.

Coordinating Center

University of Pittsburgh (Pa)

Principal Investigators: K.M. Detre, S.F. Kelsey. K. Sutton-Tyrrell, A.D. Rosen, S.W. Crow, K.H. Andrews, M.M. Brooks, R.M. Hardison, G.F. Harger, R. Holubkov, A.E. Siewers, J.P. Martin, J. Greenhouse, A. Sampson, C. Ravotti. Former participants: W.P. Amoroso, L.M. Anderson, H.X. Barnhart, D. Borrebach, J.E. Bost, D.W. Burry, M.A. Carr, M. Cooper, R.L. Hardesty, D.F. Hursh, L. Kamons, J.F. Killinger, T.E. Kuntz, E.A. Maurer, J.E. Melvin, J.A. Metzler, B.L. Naydeck, N.H. Remaley, A. Spadaro, A.R. Steenkiste, B.F. Uretsky, J. Wilson.

Program Office

Cardiac Diseases Branch, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md

Program Administrator: G. Sopko. D. Follmann, M. Horan. Former participants: M.J. Domanski, L. Offen, T. Robertson, R. Solomon, J. Verter, D. Zucker.

Safety and Data Monitoring Board

Chair: J.D. Bristow. J. Childress, T. Gardner, C. Grines, J.W. Kennedy, G. Knatterud, J. Waldhausen, C. White. Former participants: H. Gold, R. Roberts.

Morbidity and Mortality Classification Committee

Chair: R. Prineas. C. Fisch, H.L. Greene, R.B. Karp, S.B. King III, J. Mason, J.L. Titus.

Office of Study Chair

Mayo Clinic Foundation, Rochester, Minn

R.L. Frye, MD

Received February 3, 1997; revision received May 5, 1997; accepted May 15, 1997.

	References

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 

1. Abbott RD, Donahue RP, Kannel WB, Wilson PWF. The impact of diabetes on survival following myocardial infarction in men vs. women: the Framingham Study. JAMA. 1988;260:3456-3460.[Abstract]
   
2. Butler WJ, Osrander LD Jr, Carman WJ, Lamphiear DE. Mortality from coronary heart disease in the Tecumseh Study: long-term effect of diabetes mellitus, glucose intolerance, and other risk factors. Am J Epidemiol. 1985;121:541-547.[Abstract/Free Full Text]
   
3. Garcia MJ, McNamara PM, Gordon T, Kannell WB. Morbidity and mortality in diabetics in the Framingham population. Diabetes. 1974;23:105-111.[Medline] [Order article via Infotrieve]
   
4. Jarrett RJ. Type 2 (non-insulin-dependent) diabetes mellitus and coronary heart disease: chicken, egg or neither? Diabetologia. 1984;26:99-102.[Medline] [Order article via Infotrieve]
   
5. Malmberg K, Ryden L. Myocardial infarction in patients with diabetes mellitus. Eur Heart J. 1988;9:259-264.[Abstract/Free Full Text]
   
6. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12 year cardiovascular mortality from men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care. 1993;16:434-444.[Abstract]
   
7. Manske CL, Wang Y, Wilson RF, White CW. Coronary revascularization may improve short term survival in insulin-dependent diabetics considered for renal transplantation. Circulation. 1991;84(suppl II):II-516. Abstract.
   
8. Chychota MN, Gan GT, Pluth JR, Wallace RB, Danielson GK. Myocardial revascularization: comparison of operability and surgical results in diabetic and nondiabetic patients. J Thorac Cardiovasc Surg. 1973;65:856-862.[Medline] [Order article via Infotrieve]
   
9. Engelman RM, Bhat JG, Glassman E, Spencer FC, Boyd AD, Pasternak BS, Reed GE, Isom OW. The influence of diabetes and hypertension on the results of coronary revascularization. Am J Cardiol. 1975;35:135. Abstract.
   
10. McLaughlin P, Morton B, McLaughlin M, Trimble A, March J. Long-term effect of hyperlipidemia, diabetes and smoking on graft patency and progression of disease following aorto-coronary bypass. Circulation. 1974;49(suppl III):III-191. Abstract.
    
11. Verska JJ, Walker WJ. Aortocoronary bypass in the diabetic patient. Am J Cardiol. 1975;35:774-777.[Medline] [Order article via Infotrieve]
    
12. Kip K, Faxon D, Detre K, Yeh W, Kelsey SF, Currier JW. Coronary angioplasty in diabetic patients (PTCA): the NHLBI PTCA Registry. Circulation. 1996;94:1818-1825.[Abstract/Free Full Text]
    
13. Stein B, Weintraub WS, Gebhart SP, Cohen-Bernstein CL, Grosswald R, Liberman HA, Douglas JS, Morris DC, King SB. Influence of diabetes on early and late outcome after percutaneous transluminal coronary angioplasty. Circulation. 1995;91:979-989.[Abstract/Free Full Text]
    
14. Califf RM, Fortin DF, Frid DJ, Harlan WR III, Ohman EM, Bengtson JR, Nelson CL, Tcheng JE, Mark DB, Stack RS. Restenosis after coronary angioplasty: an overview. J Am Coll Cardiol. 1991;17:2B-13B.
    
15. Carrozza JP, Kuntz KE, Fishman RF, Baim DS. Restenosis after arterial injury caused by coronary stenting in patients with diabetes mellitus. Ann Intern Med. 1993;118:344-349.[Abstract/Free Full Text]
    
16. Protocol for the Bypass Angioplasty Revascularization Investigation. Circulation. 1991:84(suppl V):V-1-V-27.
    
17. Bourassa MG, Roubin GS, Detre KM, Sopko G, Krone RJ, Attabuto MJ, Bjerregaad P, Bolling S, Herman MV, Frye R, and the BARI Study Group. Bypass Angioplasty Revascularization Investigation (BARI): patient screening, selection and recruitment. Am J Cardiol. 1995;75:3C-8C.[Medline] [Order article via Infotrieve]
    
18. Rogers WJ, Alderman RL, Chaitman BR, DiSciascio G, Horan M, Lytle B, Mock MB, Rosen AD, Sutton-Tyrrell K, Weiner BH, Whitlow PL, and the BARI Study Group. Bypass Angioplasty Revascularization Investigation (BARI): baseline clinical and angiographic data. Am J Cardiol. 1995;75:9C-17C.[Medline] [Order article via Infotrieve]
    
19. Schaff HV, Rosen AD, Shemin RJ, Leclerc Y, Wareing TH, Aguirre FV, Sopko G, Vander Salm TJ, Loop FD, and the BARI Investigators. Clinical and operative characteristics of patients randomized to coronary artery bypass surgery in the Bypass Angioplasty Revascularization Investigation (BARI). Am J Cardiol. 1995;75:18C-26C.[Medline] [Order article via Infotrieve]
    
20. Williams DO, Baim DS, Bates E, Bonan R, Bost JE, Cowley M, Faxon DP, Feit F, Jones R, Kellett MA, Kelsey SF, Sopko G, Stadius M, Topol EJ, and the BARI Investigators. Coronary anatomic and procedural characteristics of patients randomized to coronary angioplasty in the Bypass Angioplasty Revascularization Investigation (BARI). Am J Cardiol. 1995;75:27C-33C.[Medline] [Order article via Infotrieve]
    
21. The BARI Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med. 1996;335:217-225.[Abstract/Free Full Text]
    
22. Mueller HS, Cohen LS, Braunwald E, Forman S, Feit F, Ross A, Schweiger M, Cabin H, Davison R, Miller D, Solomon R, Knatterud GL, for the TIMI Investigators. Predictors of early morbidity and mortality after thrombolytic therapy of acute myocardial infarction: analyses of patient subgroups in the Thrombolysis in Myocardial Infarction (TIMI) Trial, phase II. Circulation. 1992;85:1254-1264.[Abstract/Free Full Text]
    
23. Chaitman BR, Zhou SH, Tamesis B, Rosen A, Terry AB, Zumbehl KM, Stoke K, Takase B, Gussak I, Rautaharju PM. Methodology of serial ECG classification using an adaptation of the NOVACODE for Q-wave myocardial infarction in the Bypass Angioplasty Revascularization Investigation (BARI). J Electrocardiol. 1996;29:265-277.[Medline] [Order article via Infotrieve]
    
24. Prinease RJ, Crow RS, Blackburn H. The Minnesota Code Manual of Electrocardiographic Findings. Boston, Mass: John Wright PGS Inc; 1982.
    
25. Alderman EL, Stadius M. The angiographic definitions of the Bypass Angioplasty Revascularization Investigations. Coron Artery Dis. 1992;3:1189-1297.
    
26. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457-481.
    
27. Cox DR. Regression models and life-tables. J R Stat Soc (B). 1972;34:187-220.
    
28. CABRI: Long-term follow-up of European Revascularization Trials. Presented at the 68th Scientific Sessions, Plenary Session XII, of the American Heart Association, Anaheim, Calif, November 16, 1995.
    
29. King SB, Lembo NJ, Weintraub WS, Kosinski AS, Barnhart HX, Kutner MH, Alazraki NP, Guyton RA, Zhao XG, for the Emory Angioplasty Versus Surgery Trial (EAST). A randomized trial comparing coronary angioplasty with coronary bypass surgery. N Engl J Med. 1994;331:1044-1050.[Abstract/Free Full Text]
    
30. Peduzzi P, Detre K, Murphy ML, Thomsen J, Hultgren H, Takaro T, and the Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. Ten-year incidence of myocardial infarction and prognosis after infarction. Circulation. 1991;83:747-755.[Abstract/Free Full Text]
    
31. Alderman EL. Late benefit of coronary surgery on mortality from myocardial infarction. Circulation. 1991;83:1087-1089.[Free Full Text]
    
32. Jacoby RM, Nesto RW. Acute myocardial infarction in the diabetic patient: pathophysiology, clinical course and progress. J Am Coll Cardiol. 1992;20:736-744.[Abstract]
    
33. Savage MP, Krolewski AS, Kenien GG, Lebeis MP, Christlieb AR, Lewis SM. Acute myocardial infarction in diabetes mellitus and significance of congestive heart failure as a prognostic factor. Am J Cardiol. 1988;62:665-669.[Medline] [Order article via Infotrieve]
    
34. Stone PH, Muller JE, Hartwell T, York BJ, Rutherford JD, Parker CB, Turi ZG, Strauss HW, Willerson JT, Robertson T, Braunwald E, Jaffe AS, and the MILIS Study Group. The effect of diabetes mellitus on prognosis and serial left ventricular function after acute myocardial infarction: contribution of both coronary disease and diastolic left ventricular dysfunction to the adverse prognosis. J Am Coll Cardiol. 1989;14:49-57.[Abstract]
    
35. Shindler DM, Kostis JB, Yusef S, Quinones MA, Pitt B, Stewart D, Pinkett T, Ghali JK, Wilson AC, for the SOLVD Investigators. Diabetes mellitus, a predictor of morbidity and mortality in the studies of left ventricular dysfunction (SOLVD) trials and registry. Am J Cardiol. 1996;77:1017-1020.[Medline] [Order article via Infotrieve]
    
36. Smith JW, Marcus FI, Serokman R. Prognosis of patients with diabetes mellitus after acute myocardial infarction. Am J Cardiol. 1984;54:718-721.[Medline] [Order article via Infotrieve]
    
37. Shehadeh A, Regan TJ. Cardiac consequences of diabetes mellitus. Clin Cardiol. 1995;18:301-305.[Medline] [Order article via Infotrieve]
    
38. Nesto RW, Phillips RT, Kett KG, Hill T, Perper E, Young E, Leland OS. Angina and exertional myocardial ischemia in diabetic and non-diabetic patients: assessment by thallium scintigraphy. Ann Intern Med. 1988;108:170-175.
    
39. Margolis JR, Kannel SW, Feinlieb M, Dawber TR, McNamara PM. Clinical features of unrecognized myocardial infarction, silent and symptomatic: 18 year follow-up: the Framingham Study. Am J Cardiol. 1973;32:1-7.[Medline] [Order article via Infotrieve]
    
40. Zarich S, Waxman S, Freeman RT, Mittleman M, Hegarty P, Nesto RW. Effect of autonomic nervous system dysfunction on the circadian pattern of myocardial ischemia in diabetes mellitus. J Am Coll Cardiol. 1994;24:956-962.[Abstract]
    
41. Tomai F, Crea F, Gaspardone A, Versaci F, De Paulis R, Penta de Peppo A, Chiariello L, Gioffrè P. Ischemic preconditioning during coronary angioplasty is prevented by glibenclamide, a selective ATP-sensitive K⁺ channel blocker. Circulation. 1994;90:700-705.[Abstract/Free Full Text]
    
42. Cohen RA, Vanhoutte PM. Endothelium-dependent hyperpolarization: beyond nitric oxide and cyclic GMP. Circulation. 1995;92:3337-3349.[Free Full Text]
    
43. Reaven GM. Role of insulin resistance in human disease. Diabetes. 1988;37:1595-1607.[Abstract]
    
44. Nahser PJ, Brown RE, Oskarsson H, Winniford MD, Rossen JD. Maximal coronary flow reserve and metabolic coronary vasodilation in patients with diabetes mellitus. Circulation. 1995;91:635-640.[Abstract/Free Full Text]
    
45. Sobel BE. Altered fibrinolysis and platelet function in the development of vascular complications of diabetes. Curr Opin Endocrinol Diabetes. 1996;3:355-360.
    
46. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977-986.[Abstract/Free Full Text]
    
47. Laakso M. Glycemic control and the risk for coronary heart disease in patients with non-insulin-dependent diabetes mellitus. Ann Intern Med. 1996;124:127-130.[Abstract/Free Full Text]
    
48. Malmberg K, Ryden L. Intense metabolic control decreases long-term mortality and morbidity in diabetes with myocardial infarction. J Am Coll Cardiol. 1996;27(2 suppl A):82A. Abstract.
    
49. Yudkin JS. How can we best prolong life? Benefits of coronary risk factor reduction in nondiabetic and diabetic subjects. Br Med J. 1993;306:1313-1318.
    
50. Detre K, Rosen A, Jones R, Rogers W, Mock M, Faxon D, Bourassa M, Feit F, Cowley M, Loop F, and the BARI Investigators. Is five-year mortality different for treatment by choice vs. random assignment in the Bypass Angioplasty Revascularization Investigation (BARI). J Coll Cardiol. 1996;29(suppl):243A. Abstract.
    
51. Serruys PW, de Jaegere P, Kiemeneij F, Macaya C, Rutsch W, Heyndrickx G, Emanuelsson H, Marco J, Legrand V, Materne P, Belardi J, Sigwart U, Colombo A, Goy JJ, van den Heuvel P, Delcan J, Morel M-A, for the Benestent Study Group. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med. 1994;331:489-495.[Abstract/Free Full Text]
    
52. Fischman DL, Leon MB, Baim DS, Schatz RA, Savage MP, Penn I, Detre K, Veltri L, Ricci D, Nobuyoshi M, Cleman M, Heuser R, Almond D, Teirstein PS, Fish RD, Colombo A, Brinker J, Moses J, Shaknovich A, Hirshfeld J, Bailey S, Ellis S, Rake R, Goldberg S, for the Stent Restenosis Study Investigators. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med. 1994;331:496-501.[Abstract/Free Full Text]
    
53. Warth DC, Leon MB, O'Neill W, Zacca N, Polissar NL, Buchbinder M. Rotational Atherectomy Multicenter Registry: acute results, complications and 6-month follow-up in 709 patients. J Am Coll Cardiol. 1994;24:641-648.[Abstract]
    

This article has been cited by other articles:

				J. Booth, T. Clayton, J. Pepper, F. Nugara, M. Flather, U. Sigwart, R. H. Stables, and on Behalf of the SoS Investigators Randomized, Controlled Trial of Coronary Artery Bypass Surgery Versus Percutaneous Coronary Intervention in Patients With Multivessel Coronary Artery Disease: Six-Year Follow-Up From the Stent or Surgery Trial (SoS) Circulation, July 22, 2008; 118(4): 381 - 388. [Abstract] [Full Text] [PDF]

				S. R. Mulukutla, H. A. Vlachos, O. C. Marroquin, F. Selzer, E. M. Holper, J. D. Abbott, W. K. Laskey, D. O. Williams, C. Smith, W. D. Anderson, et al. Impact of Drug-Eluting Stents Among Insulin-Treated Diabetic Patients: A Report From the National Heart, Lung, and Blood Institute Dynamic Registry J. Am. Coll. Cardiol. Intv., April 1, 2008; 1(2): 139 - 147. [Abstract] [Full Text] [PDF]

				A J H A Scholte, J D Schuijf, A V Kharagjitsingh, J W Jukema, G Pundziute, E E van der Wall, and J J Bax Prevalence of coronary artery disease and plaque morphology assessed by multi-slice computed tomography coronary angiography and calcium scoring in asymptomatic patients with type 2 diabetes Heart, March 1, 2008; 94(3): 290 - 295. [Abstract] [Full Text] [PDF]

				P. Ortolani, M. Balducelli, P. Marzaroli, G. Piovaccari, A. Menozzi, V. Guiducci, P. Sangiorgio, F. Tarantino, G. Geraci, F. Castriota, et al. Two-Year Clinical Outcomes With Drug-Eluting Stents for Diabetic Patients With De Novo Coronary Lesions: Results From a Real-World Multicenter Registry Circulation, February 19, 2008; 117(7): 923 - 930. [Abstract] [Full Text] [PDF]

				M. L. Brown, T. M. Sundt III, and B. J. Gersh Indications for Revascularization Card. Surg. Adult, January 1, 2008; 3(2008): 551 - 572. [Full Text]

				F. Filsoufi, P. B. Rahmanian, J. G. Castillo, J. I. Mechanick, S. K. Sharma, and D. H. Adams Diabetes is not a risk factor for hospital mortality following contemporary coronary artery bypass grafting Interactive CardioVascular and Thoracic Surgery, December 1, 2007; 6(6): 753 - 758. [Abstract] [Full Text] [PDF]

				D. M. Bravata, A. L. Gienger, K. M. McDonald, V. Sundaram, M. V. Perez, R. Varghese, J. R. Kapoor, R. Ardehali, D. K. Owens, and M. A. Hlatky Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery Ann Intern Med, November 20, 2007; 147(10): 703 - 716. [Abstract] [Full Text] [PDF]

				C.-C. Fang, Yeun Tarl Fresner Ng Jao, Yi-Chen, C.-L. Yu, C.-L. Chen, and S.-P. Wang Angiographic and Clinical Outcomes of Rosiglitazone in Patients With Type 2 Diabetes Mellitus After Percutaneous Coronary Interventions: A Single Center Experience Angiology, November 1, 2007; 58(5): 523 - 534. [Abstract] [PDF]

				A. Avignon, A. Sultan, C. Piot, D. Mariano-Goulart, J.-F. Thuan dit Dieudonne, J. P. Cristol, and A. M. Dupuy Osteoprotegerin: A Novel Independent Marker for Silent Myocardial Ischemia in Asymptomatic Diabetic Patients Diabetes Care, November 1, 2007; 30(11): 2934 - 2939. [Abstract] [Full Text] [PDF]

				A. Javaid, D. H. Steinberg, A. N. Buch, P. J. Corso, S. W. Boyce, T. L. Pinto Slottow, P. K. Roy, P. Hill, T. Okabe, R. Torguson, et al. Outcomes of Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention With Drug-Eluting Stents for Patients With Multivessel Coronary Artery Disease Circulation, September 11, 2007; 116(11_suppl): I-200 - I-206. [Abstract] [Full Text] [PDF]

				J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): e1 - e157. [Full Text] [PDF]

				J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): 652 - 726. [Full Text] [PDF]

				P. Jimenez-Quevedo, M. Sabate, D. J. Angiolillo, F. Alfonso, R. Hernandez-Antolin, M. SanMartin, J. A. Gomez-Hospital, C. Banuelos, J. Escaned, R. Moreno, et al. Long-term clinical benefit of sirolimus-eluting stent implantation in diabetic patients with de novo coronary stenoses: long-term results of the DIABETES trial Eur. Heart J., August 2, 2007; 28(16): 1946 - 1952. [Abstract] [Full Text] [PDF]