Revascularization Trumps Medicine for Patients With Type 2 Diabetes Mellitus and Chronic Angina (or Does It?)

Abstract

Chronic angina is the most common clinical manifestation of ischemic heart disease, affecting as many as 54 million people globally1 and over 10 million people in the United States.2 The prevalence of angina varies by region, and tends to affect more women than men. Although difficult to quantify, the lifetime cost of managing chronic angina approaches 1 million dollars.3 Article see p 1492 The explicit goals of therapy for managing chronic angina are to prevent major cardiovascular complications, namely nonfatal myocardial infarction/cardiovascular death, and improve quality of life.4 Both the Canadian Cardiovascular Society (CCS) classification and the Seattle Angina Questionnaire (SAQ) are frequently used in both clinical trials and practice to quantify angina severity. Although common and simple to administer, CCS is relatively insensitive in discriminating angina severity, which limits its usefulness in evaluating therapeutic efficacy and quantifying patients' functional status. The SAQ is a patient-assessed questionnaire used to quantify 5 domains: physical limitation, change in angina symptoms, angina frequency, treatment satisfaction, and quality of life.5 In this issue of Circulation , Dagenais et al from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) study group report on the effectiveness of an initial strategy of optimal medical therapy with coronary revascularization versus optimal medical therapy alone in treating angina among patients with type 2 diabetes mellitus and ischemic heart disease.6 This planned substudy was designed to evaluate angina and quality of life in the 2368 such patients from BARI 2D (http://www.clinicaltrials.gov/ct2/show/NCT00006305).7 As previously reported, the main study findings demonstrated no significant differences in serious adverse cardiovascular events, including death, nonfatal myocardial infarction, or stroke at 5 years between revascularization or medical therapy alone. In the present analysis, initial coronary revascularization was superior to medical therapy in maintaining freedom from angina, preventing …