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488 Cardio Diabetes Medicine 2017

ization in these patients, supporting their preferential intake of saturated fats (to <7% of total calories), trans
use, these patients still experience more restenosis. fatty acids (to <1% of total calories), and cholesterol
(to <200 mg/day). In addition to therapeutic lifestyle
Coronary Artery Bypass Grafting versus changes, a moderate or high dose of a statin should
Percutaneous Coronary Intervention be prescribed in the absence of contraindications or
documented adverse effects.For patients who do not
In general, randomized trials comparing PCI and tolerate statins, LDL cholesterol–lowering therapy with
CABG have reported similar outcomes. In patients bile acid sequestrants, niacin or both is reasonable.
with diabetes, however, CABG yields superior mor-
tality outcomes compared with PCI, with incremen- Type 2 diabetes is associated with a characteristic
tal benefit associated with increasing severity of pattern of dyslipidemia but statin treatment remains
underlying coronary artery disease.(BARI) trial. The the cornerstone of therapeutic lipid intervention in
mortality benefit of CABG over PCI remains despite patients with diabetes endorsing a target of LDL
the widespread availability of drug-eluting stents and less than 100 mg/dL or 35% to 40% reduction from
other advances in devices, techniques, and adjunc- baseline. An optional, more intensive target has been
tive pharmacotherapy(FREEDOM randomized trial). endorsed for patients with diabetes of LDL choles-
Therefore CABG continues to be recommended as terol below 70 mg/dL and non-HDL cholesterol less
the preferred mode of revascularization for patients than 100 mg/dL.
with diabetes and multivessel coronary disease.11
Blood Pressure Management
Revascularization Versus Optimal Medical Patients with diabetes should be treated to
Therapy achieve a systolic blood pressure (SBP) at least < 140
mm Hg and a diastolic blood pressure (DBP) < 90
The BARI 2D trial randomly assigned 2368 patients mm Hg, and for patients who can tolerate without
with type 2 diabetes and obstructive coronary artery adverse symptoms, can target as low as SBP < 130
disease to receive prompt reduction, or to intensive and DBP < 80. Patients with a systolic blood pressure
medical therapy alone. During 5 years of study fol- of 130 to 139 mm Hg or a diastolic blood pressure
low-up, the overall mortality rates between the two of 80 to 89 mm Hg should initiate lifestyle modi-
groups did not differ significantly—11.7% in those un- fication alone (weight control, increased physical
dergoing revascularization, and 12.2% in those treat- activity, alcohol moderation, sodium reduction, and
ed with intensive medical therapy alone (P = 0.97). In emphasis on increased consumption of fresh fruits,
secondary analyses stratified according to the mode vegetables, and low-fat dairy products) for a maxi-
of revascularization, all cardiovascular outcomes mum of 3 months. If, after these efforts, targets are
were statistically similar between the PCI and medi- not achieved, treatment with pharmacologic agents
cal therapy groups, but CABG compared with medical should be initiated.
therapy was associated with a significant reduction
in major adverse cardiovascular events (22.4% ver- ACE inhibitors and angiotensin II receptor blockers
sus 30.5%; P = 0.01). These data provide support for (ARBs) have become cornerstones of therapy for
an initial strategy of intensive medical therapy and hypertension in diabetes because of their broadly
additionally suggest the benefit of bypass surgery. demonstrated favorable effects on diabetic nephrop-
athy and CVD outcomes, as well as their modest fa-
While recommendations for coronary intervention by vorable effects on measures of glucose metabolism.
percutaneous coronary intervention (PCI) or CABG
should be mainly evidence-based, the overall clinical Dihydropyridine calcium channel blockers generally
picture (e.g. advanced age, significant co-morbidities, are well tolerated and effectively lower blood pres-
need for dual antiplatelet medication) as well as pa- sure.
tient preferencesand cost should also be considered.
Antagonists of beta-adrenergic receptors (beta block-
ers) are another key component of effective CVD risk
Guideline Directed Optimal Medical reduction in diabetes.
Treatment
Early in the course of clinical use, beta blockers
Risk Factor Modification were judged to be relatively contraindicated in the
setting of diabetes because of concerns about mask-
Lipid Management ing hypoglycemia symptoms and adverse effects on
glucose and lipid metabolism. The results of CVD
Dietary therapy for all patients should include reduced outcomes trials have allayed these concerns and

GCDC 2017