General Cardiology Perspective: Decision Making Regarding Revascularization of Patients With Type 2 Diabetes Mellitus and Cardiovascular Disease in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial

The interest in the diabetic population undergoing coronary revascularization began with the reporting of the Bypass Angioplasty Revascularization Investigation (BARI) trial in 1996.1 In patients with multivessel disease, a post hoc analysis demonstrated a significant survival advantage for patients in the coronary artery bypass grafting (CABG) arm compared with those undergoing balloon angioplasty. This striking finding sensitized the cardiovascular community to the unique nature of diabetic coronary disease. A comprehensive meta-analysis of percutaneous coronary intervention (PCI) versus CABG trials before the drug-eluting era has confirmed the BARI findings.2 Over the next decade, there were tremendous advances in medical risk factor modification, particularly the widespread use of statin drugs and improvements in therapies for glycemic control. The BARI 2 Diabetes (BARI 2D) investigators posed the next important question about optimal management of coronary disease in patients with less severe symptomatology than those enrolled in the multivessel PCI versus CABG trials.3 About 80% of patients were either asymptomatic or had stable class I/II Canadian Cardiovascular Society angina. In this trial, the comparison was now between prompt revascularization on top of optimal medical therapy (OMT) versus OMT alone. BARI 2D heralded in a new era in National Heart, Lung, and Blood Institute–sponsored trials by exclusively studying patients with type 2 diabetes mellitus. BARI 2D demonstrated no difference in 5-year mortality between the prompt revascularization and OMT alone arms (11.7% versus 12.2%; P =0.97) as well as no difference in 5-year rates of the combined end point of death, myocardial infarction, and stroke (22.8% versus 24.1%; P =0.70).The most efficient way to evaluate the impact of BARI 2D on practice is to evaluate the patients studied and the interventions that were applied. The PatientsBARI 2D randomized patients with demonstrated ischemia who were either asymptomatic or who had mild to moderate symptoms. …