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In this report, we examine angiographic and clinical risk scores in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial to test the hypothesis that differences in the end points of death and myocardial infarction and the composite end points of death/myocardial infarction/stroke and cardiac death/ myocardial infarction observed between coronary revascularization and intensive medical therapy might be related to coronary disease extent and clinical characteristics. In the group of patients in whom percutaneous coronary intervention was chosen as the preferred revascularization option, there were no treatment differences between an initial strategy of percutaneous coronary intervention or intensive medical therapy regardless of angiographic or clinical risk score. This was not the case in the patients in whom coronary artery bypass graft surgery was selected as the preferred revascularization option because there was an increasing benefit of coronary artery bypass graft surgery in terms of reduction of cardiac end points in the highest-angiographic-risk patients, particularly in those with high clinical risk scores. Our findings indicate that among patients with diabetes mellitus and stable ischemic heart disease, a strategy of prompt coronary artery bypass graft surgery is preferred to an initial strategy of intensive medical therapy for those with extensive coronary artery disease or impaired left ventricular function to reduce the rates of myocardial infarction and death/myocardial infarction/stroke.