Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D)

Abstract

Objectives: The purpose of this analysis was to assess in patients with type 2 diabetes and stable coronary artery disease, (CAD) whether the risk of all-cause mortality and cardiovascular events varied according to the presence or absence, of angina and angina equivalent symptoms. Background: Data on the prognostic value of symptoms in these patients are limited. Methods Post-hoc analysis was performed in 2,364 patients with type 2 diabetes and documented CAD enrolled in the, BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial to determine the occurrence of, death and composite of death, myocardial infarction, and stroke during a 5-year follow-up according to cardiac symptoms at baseline. Results: There were 1,434 patients with angina (A), 506 with angina equivalents (E), and 424 with neither of these (N). The cumulative death rates (total 316) were 12% in A, 14% in E, and 10% in N (p 0.3), and cardiovascular composite rates (total 548) were 24% in A, 24% in E, and 21% in N (p 0.5). Compared with N, the hazard ratios adjusted for confounders were not different for death in A (1.11; 99% CI: 0.81 to 1.53) and E (1.17; 99% CI: 0.81 to 1.68) or for cardiovascular events in A (1.17; 99% CI: 0.92 to 1.50) and E (1.11; 99% CI: 0.84 to 1.48). Conclusions: Whatever their symptom status, patients with type 2 diabetes and stable CAD were at similar risk of cardiovascular events and death. These findings suggest that these patients may be similarly managed in terms of risk stratification and preventive therapies. (Bypass Angioplasty Revascularization Investigation 2 Diabetes [BARI 2D]; {type:clinical-trial,attrs:{text:NC6305,term_id:NC6305}}NC6305) (J Am Coll Cardiol 2013;61:702–11) © 2013 by the American College of Cardiology Foundation Diabetes mellitus (DM) is a global epidemic. Accelerated atherosclerosis in DM leads to high incidence of Cardiovascular Disease (CVD). Coronary Artery Disease (CAD) accounts for large fraction of morbidity, mortality and cost of DM. In Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, it was analyzed whether symptoms affect prognosis or not in Type 2 DM and CAD with documented ischemia. A total of 2368 patients with Type 2DM and stable CAD with documented ischemia were followed up for 5.3 years. Patients were divided into those with angina, angina equivalent (dyspnea, palpitation or diaphoresis on exertion) or no cardiac symptom. Stable CAD and Type 2DM had similar long term prognosis across a variety of cardiovascular outcome irrespective of their symptomatic status. Five-year death rate was 12% with angina, 14% with angina equivalent, and 10% in asymptomatic patient. Cumulative 5-year composite outcome rate were 24%, 24% and 21%, respectively. Asymptomatic patients were at the same relative high risk for all cause mortality, the composite outcome, CVD death, nonfatal myocardial infarction (MI) and nonfatal stroke, compared to patients with angina or angina equivalent. These were independent of baseline characteristics, severity of CAD and coronary revascularization. In separate analysis of optimized medical therapy and revascularization, the outcome remained unchanged. Left ventricular systolic function was normal in all three groups. Exercise induced ischemia causing diastolic dysfunction could be responsible for exertional dyspnea qualifying angina equivalent. Summarizing, the take home message of this study is that Type 2DM, stable CAD with documented ischemia and no symptoms are at the same high risk for all cause mortality and major cardiovascular outcomes compared to those with angina or angina equivalent. These patients should be similarly managed in terms of risk stratification and preventive therapy.