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Cardio Diabetes Medicine 2017 393

versus 11.9% in the on-pump group (P=0.02). The rate elective PCI should receive 2 or 3 generation Drug
rd
nd
of major adverse cardiovascular events at 5 years eluting stents preferably Everolimus based stents.
was 31.0% in the off-pump group versus 27.1% in the Duration of DAPT in diabetics will need to managed
on-pump group (P=0.046). For the 5-year secondary on the basis of risk benefit ratio. The DAPT score
outcomes, no significant differences were observed: can help with this analysis. Usually diabetics have
for nonfatal myocardial infarction, for death from more extensive disease and benefit from longer term
cardiac causes, for repeat revascularization, and for DAPT.
repeat CABG.
Syntax score
PCI for treatment of CAD Syntax score was an anatomic score designed to

The development of the first-generation DES (siro- objectively assess extent and complexity of CAD.
limus and paclitaxel) was a major breakthrough in This was initially done to help with randomization
PCI, especially in patients with Diabetes. it reduced of complex CAD patients for trials. It is an angio-
the incidence of restenosis in comparison to BMS. graphic tool to grade CAD complexity. The concept
In fact, a meta-analysis of 35 trials(10) showed that of SYNTAX score was prospectively validated in the
first-generation DES decreased target lesion revas- SYNTAX (14)trial. Using tertiles of the anatomic SYN-
cularization (TLR) when compared with BMS. Never- TAX score (low <23, intermediate 23 to 32, high ≥33)
theless, no difference in overall mortality, MI or stent in SYNTAX trial, patients were randomized to CABG
thrombosis was shown. Safer stent technology led versus multi-vessel PCI. Outcomes varied based on
to the development of the second-generation DES. the SYNTAX score.
A meta-analysis of 42 trials published in 2012 (12) SYNTAX score can be calculated using an online
analyzed five stent types – BMS, first-generation DES tool- www.syntaxscore.com.
and second-generation DES – in 10,714 patients with
diabetes (with 22,844 patient years of follow-up). In Trials comparing CABG to PCI in CAD
this study, all DES were associated with a significant Multiple randomized trials have addressed the issue
reduction in TVR (37% to 69%) when compared with of CABG vs PCI for revascularization of multi-vessel
BMS; however, the efficacy varied with the type of coronary artery disease in patients with diabetes mel-
DES. EES was found to be the most efficacious and litus. While the debate over whether CABG or PCI is
safe stent and it had the highest probability of being the preferred mode of revascularization in diabetics
associated with the lowest rate of TVR, MI and any as lingered on, the value of revascularization over
stent thrombosis. (optimum medical therapy) OMT in patients with

The recent publication of the results of the TUXEDO stable CAD has itself been questioned. In the BARI
trial (13)”container-title”:”The New England journal 2D (Bypass Angioplasty Revascularization Investiga-
of medicine”,”page”:”1709-1719”,”volume”:”373”,”is- tion 2 Diabetes) study, a strategy of revasculariza-
sue”:”18”,”abstract”:”BACKGROUND: The choice of tion (CABG or PCI) + OMT was no better than OMT
drug-eluting stent in the treatment of patients with to reduce the risk of death or major cardiovascular
diabetes mellitus and coronary artery disease who events (MACE) (death, MI, or stroke). Similarly, in
are undergoing percutaneous coronary intervention the COURAGE trial, PCI did not reduce the risk of
(PCIgave some more insight in this context. In this death or MI, even in those with diabetes. However,
study, 1,788 patients with DM were randomized to in the BARI 2D trial, CABG reduced MACE over OMT,
receive PES (889 patients) or EES (899 patients). The mainly driven by a significant reduction in MI (7.4% vs.
primary endpoint was TVF (defined as a composite 14.6%), but not mortality (14.0% vs. 16.9%). Despite this,
of cardiac death, target vessel MI or ischemia-driv- the 2014 American College of Cardiology/American
en TVR). At one year, PES did not meet the criterion Heart Association stable ischemic heart disease
for non-inferiority to EES with respect to the primary guidelines recommend OMT, even in patients with
endpoint (5.6% vs. 2.9%; p=0.38 for non-inferiority). In diabetes, and revascularization is recommended only
addition, there was a significantly higher 1-year rate in patients whose symptoms compromise quality of
in the PES group of spontaneous MI (3.2% vs. 1.2%; life, despite OMT.
p=0.0004), stent thrombosis (2.1% vs. 0.4%; p=0.002), It must be highlighted that a considerable proportion
TVR (3.4% vs. 1.2%; p=0.002), and TLR (3.4% vs. 1.2%; of patients who crossed over from OMT alone to re-
p=0.002).
vascularization in the COURAGE (33%) and BARI 2D
In current practice, patients with DM who undergo (42%) trials makes it harder to consider OMT alone
as a treatment option, but more appropriately OMT

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