Bypass Angioplasty Revascularization Investigation Research Articles

Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D)

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.

Impact of ischemia and scar on therapeutic benefit of myocardial revascularization

The question of how to optimally manage coronary artery disease (CAD) has been a challenge for the cardiology community. The results of early, large randomized clinical trials (RCTs) comparing strategies of medical therapy alone versus revascularization plus medical therapy in patients with stable CAD suggested a survival advantage for a revascularization strategy in the setting of more advanced, higher-risk CAD (left main, three-vessel CAD), but a superiority of medical therapy in patients with more limited, relatively lower-risk CAD (one vessel, limited two-vessel CAD). The results of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trials redefined the management of CAD, supporting the concept that the impact of aggressively applied modern "medical therapy" on patient survival and patient-reported outcomes is not further improved by the addition of percutaneous intervention. On the other hand, RCTs incorporating fractional flow reserve have shown that this physiologic metric can help identify which patients will benefit from a revascularization strategy. This paradigm has been extended to the use of myocardial perfusion imaging-identified ischemia to determine which patients may have enhanced survival with early revascularization versus medical therapy. Although data from a series of observational studies suggest that inducible ischemia on myocardial perfusion scintigraphy can identify revascularization candidates, several studies, including substudies from major RCTs, do not support this idea. Until RCTs comparing revascularization with medical therapy strategies are performed, many questions remain open. The correct thresholds for treatment, the metric to guide treatment, and how revascularization should be performed are as yet undefined.

Risk Factor Control for Coronary Artery Disease Secondary Prevention in Large Randomized Trials

This study evaluated data from 3 federally funded trials that focused on optimal medical therapy to determine if formalized attempts at risk factor control within clinical trials are effective in achieving guideline-driven treatment goals for diabetic patients with coronary artery disease (CAD). Despite clear evidence of benefit for CAD secondary prevention, the level of risk factor control in clinical practice has been disappointing. We obtained data from the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) diabetes subgroup, (n = 766 of 2,287), the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial (n = 2,368), and the FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900) to evaluate the proportion of patients achieving guideline-based, protocol-driven treatment targets for systolic blood pressure, low-density lipoprotein cholesterol, smoking cessation, and hemoglobin A1c. The primary outcome measure was the proportion of diabetic CAD patients meeting all 4 pre-specified targets at 1 year after enrollment. The pooled data include 5,034 diabetic patients. The percentages of patients achieving the 1-year low-density lipoprotein cholesterol targets compared with baseline increased from 55% to 77% in COURAGE, from 59% to 75% in BARI 2D, and from 34% to 42% in FREEDOM. Although similar improved trends were seen for systolic blood pressure, glycemic control, and smoking cessation, only 18% of the COURAGE diabetes subgroup, 23% of BARI 2D patients, and 8% of FREEDOM patients met all 4 pre-specified treatment targets at 1 year of follow-up. A significant proportion of diabetic CAD patients fail to achieve pre-specified targets for 4 major modifiable cardiovascular risk factors in clinical trials. We conclude that fundamentally new thinking is needed to explore approaches to achieve optimal secondary prevention treatment goals. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation; NCT00007657) (Bypass Angioplasty Revascularization Investigation 2 Diabetes [BARI 2D]; NCT00006305) (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450).

Sex Differences in Presentation and Outcome Among Patients With Type 2 Diabetes and Coronary Artery Disease Treated With Contemporary Medical Therapy With or Without Prompt Revascularization: A Report From the BARI 2D Trial (Bypass Angioplasty Revascularization Investigation 2 Diabetes)

This study evaluated differences in outcome among women and men enrolled in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. Women and men with coronary artery disease have different clinical presentations and outcomes that might be due to differences in management. We compared baseline variables, study interventions, and outcomes between women and men enrolled in the BARI 2D trial and randomized to aggressive medical therapy alone or aggressive medical therapy with prompt revascularization. At enrollment, women were more likely than men to have angina (67% vs. 58%, p < 0.01) despite less disease on angiography (Myocardial Jeopardy Index 41 ± 24 vs. 46 ± 24, p < 0.01; number of significant lesions 2.3 ± 1.7 vs. 2.8 ± 1.8, p < 0.01). Over 5 years, no sex differences were observed in BARI 2D study outcomes after adjustment for difference in baseline variables (death/myocardial infarction/cerebrovascular accident: hazard ratio: 1.11, 99% confidence interval [CI]: 0.85 to 1.44). However, women reported more angina than men (adjusted odds ratio: 1.51, 99% CI: 1.21 to 1.89, p < 0.0001) and had lower scores for the Duke Activity Status Index (adjusted beta coefficient: -1.58, 99% CI: -2.84 to -0.32, p < 0.01). There were no sex differences in death, myocardial infarction, or cerebrovascular accident among patients enrolled in the BARI 2D trial. However, compared with men, women had more symptoms and less anatomic disease at baseline, with persistence of higher angina rates and lower DASI scores after 5 years of medical therapy with or without prompt revascularization. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305).

Quantification of myocardial area at risk in the absence of collateral flow: The validation of angiographic scores by myocardial perfusion single-photon emission computed tomography

ObjectivesOur study aimed to compare the area at risk (AAR) determined by single-photon emission computed tomography (SPECT) with the Bypass Angioplasty Revascularization Investigation (BARI) and modified Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) angiographic scores in the setting of patients undergoing coronary angioplasty for either unstable angina or an STEMI. BackgroundRadionuclide myocardial perfusion imaging prior to reperfusion has classically been the most widely practised technique for assessing the AAR and has been successfully used to compare the efficacy of various reperfusion strategies in patients with an ST-segment elevation myocardial infarction (STEMI). The BARI and modified APPROACH scores are angiographic methods widely used to provide a rapid estimation of the AAR; however, they have not been directly validated with myocardial perfusion single-photon emission computed tomography (SPECT). MethodsFifty-five patients with no previous myocardial infarction who underwent coronary angioplasty for single-vessel disease (unstable angina: n = 25 or an STEMI: n = 30) with no evidence of collaterals (Rentrop Collateral Score <2) were included in a prospective study. In STEMI patients, the 99mTc-tetrofosmin was injected prior to opening of the occluded vessel and, in patients with unstable angina after 10-15 seconds of balloon inflation. Acquisition was performed with a dual-head gammacamera with a low-energy and high-resolution collimator. A total of 60 projections were acquired using a non-circular orbit. No attenuation or scatter correction was used. Maximal contours of hypoperfusion regions corresponding to each coronary artery occlusion were delineated over a polar map of 17 segments and compared with the estimated AAR determined by two experienced interventional cardiologists using both angiographic scores. ResultsMean AAR percentage in SPECT was 35.0 (10.0%-56.0%). A high correlation was found between BARI and APPROACH scores (r= 0.9, P< .001). Furthermore, a high correlation was also observed between BARI versus SPECT and APPROACH versus SPECT to estimate the AAR (r= 0.9, P< .001 and r= 0.8, P< .001, respectively). Better correlations were observed when the left anterior descending artery (LAD) was revascularized (r= 0.8, P< 0.001 with BARI; r= 0.8, P= .001 with APPROACH) compared to other territories (r= 0.8, P= .001 with BARI; r= 0.7, P= .001 with APPROACH). Also, better correlations were observed in patients who underwent an elective rather than a primary percutaneous revascularization procedure. ConclusionsIn the absence of collateral flow, BARI and APPROACH scores constitute valid methods for AAR estimation in current clinical practice, with more accurate results when used for the LAD territory; both are useful not only in STEMI patients but also in patients with unstable angina.

Prognostic Impact of the Presence and Absence of Angina on Mortality and Cardiovascular Outcomes in Patients With Type 2 Diabetes and Stable Coronary Artery Disease

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. Data on the prognostic value of symptoms in these patients are limited. 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. 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). 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]; NCT00006305).

Complete Revascularization in Contemporary Practice

In patients with acute coronary syndrome (ACS), the pathophysiological process is not limited to a single coronary lesion but involves the entire coronary tree, with 30% to 60% patients presenting with multiple significant coronary lesions, with significant increase in cardiovascular morbidity and mortality in patients with multivessel coronary artery disease.1,2 In the Predictors of Events in the Coronary Tree trial, patients with ACS who underwent percutaneous coronary intervention (PCI), major adverse cardiovascular events occurring during follow-up were equally attributable to recurrence at the site of culprit lesions and to nonculprit lesions, which were frequently angiographically mild.3 In contrast, in the COURAGE trial in patients with stable coronary artery disease (CAD) on optimal medical therapy, the only angiographic predictor of future ACS was the number of lesions originally ≥50% that had not been revascularized.4 The above studies attest to the importance of both angiographically significant lesions as well as angiographically mild lesions on future events. These studies highlight the importance of a multipronged approach with the use of evidence-based aggressive medical management (to prevent progression of angiographically mild and also significant CAD), as well as judicious use of optimal revascularization strategies. Several surgical studies have shown that incomplete revascularization in patients undergoing coronary artery bypass graft surgery has worse prognosis with higher mortality, myocardial infarction (MI), and more angina.5–7 As a result, complete anatomic revascularization has become the standard of treatment for coronary artery bypass graft surgery. The concept has been adapted by interventionalist to patients undergoing PCI with several studies (nonrandomized), including an analysis from the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial8 showing substantial increase in cardiovascular events with incomplete revascularization. Similarly, in the Acute Catheterization and Urgent Intervention Triage Strategy trial of patients with nonST-segment elevation ACS, incomplete revascularization …

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Tree-based identification of subgroups for time-varying covariate survival data

Classification and regression tree analyses identify subsets of a sample that differ on an outcome. Discrimination of subsets is performed using recursive binary splitting on a set of covariates, allowing for interactions of variable subgroups not easily captured in standard model building techniques. Using classification and regression tree with epidemiological data can be problematic as there is often a need to adjust for potential confounders and to account for time-varying covariates in the context of right-censored survival data. While classification and regression tree variations exist individually for survival analysis, time-varying covariates and incorporating possible confounders, examples of classification and regression tree using all three together are lacking. We propose a method to identify subsets of time-varying covariate risk factors that affect survival while adjusting for possible confounders. The technique is demonstrated on data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes clinical trial to find combinations of modifiable time-varying cardiac risk factors (e.g. smoking status, blood pressure, lipid levels and HbA1c level) that are associated with time-to-event clinical outcomes.

Ankle-brachial index and cardiovascular outcomes in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial

Peripheral arterial disease increases cardiovascular risk in many patient populations. The risks associated with an abnormal ankle-brachial index (ABI) in patients with type 2 diabetes and stable coronary artery disease have not been well described with respect to thresholds and types of cardiovascular events. We examined 2,368 patients in the BARI 2D trial who underwent ABI assessment at baseline. Death and major cardiovascular events (death, myocardial infarction and stroke) during follow-up (average 4.3 years) were assessed across the ABI spectrum and by categorized ABI: low (≤0.90), normal (0.91-1.3), high (>1.3), or noncompressible. A total of 12,568 person-years were available for mortality analysis. During follow-up, 316 patients died, and 549 had major cardiovascular events. After adjustment for potential confounders, with normal ABI as the referent group, a low ABI conferred an increased risk of death (relative risk [RR] 1.6, CI 1.2-2.2, P = .0005) and major cardiovascular events (RR 1.4, CI 1.1-1.7, P = .004). Patients with a high ABI had similar outcomes as patients with a normal ABI, but risk again increased in patients with a noncompressible ABI with a risk of death (RR 1.9, CI 1.3-2.8, P = .001) and major cardiovascular event (RR 1.5, CI 1.1-2.1, P = .01). In patients with coronary artery disease and type 2 diabetes, ABI screening and identification of ABI abnormalities including a low ABI (<1.0) or noncompressible artery provide incremental prognostic information.

Daily n-3 fatty acid supplements did not reduce CV events in high-risk patients with dysglycemia

ACP Journal Club18 September 2012Daily n-3 fatty acid supplements did not reduce CV events in high-risk patients with dysglycemiaEllis Lader, MDEllis Lader, MDMid Valley Cardiology, New York University School of Medicine, Kingston, New York, USA (E.L.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-157-6-201209180-02011 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationORIGIN Trial Investigators, Bosch J, Gerstein HC, et al. n-3 fatty acids and cardiovascular outcomes in patients with dysglycemia. N Engl J Med. 2012;367:309-18. https://pubmed.ncbi.nlm.nih.gov/22686415Clinical Impact RatingsGIM/FP/GP: Cardiology: Endocrinology: References1 Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977-86. [PMID: 8366922] Google Scholar2 Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358:2545-59. [PMID: 18539917] Google Scholar3 ADVANCE Collaborative Group, Patel A, MacMahon S, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560-72. [PMID: 18539916] Google Scholar4 Duckworth W, Abraira C, Moritz T, et al; VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360:129-39. [PMID: 19092145] Google Scholar5 Sobel BE, Hardison RM, Genuth S, et al; BARI 2D Investigators. Profibrinolytic, antithrombotic, and antiinflammatory effects of an insulin-sensitizing strategy in patients in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Circulation. 2011;124:695-703. [PMID: 21768545] Google Scholar6 Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403. [PMID: 11832527] Google Scholar7 Daviglus ML, Stamler J, Orencia AJ, et al. Fish consumption and the 30-year risk of fatal myocardial infarction. N Engl J Med. 1997;336:1046-53. [PMID: 9091800] Google Scholar Author, Article, and Disclosure InformationAffiliations: Mid Valley Cardiology, New York University School of Medicine, Kingston, New York, USA (E.L.)This article was published at Annals.org on 4 September 2012. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoGlargine did not reduce CV events more than standard care in patients with dysglycemia Ellis Lader Metrics 18 September 2012Volume 157, Issue 6Page: JC3-11KeywordsArrhythmiaFatty acidsGlucoseHbA1cHypoglycemiaInsulinMyocardial infarctionOilsType 2 diabetes ePublished: 18 September 2012 Issue Published: 18 September 2012 Copyright & PermissionsCopyright © 2012 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

326 Disparity Between Clinical Trials and Registry Outcomes: Reflections From the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI-2D) Trial

326 Disparity Between Clinical Trials and Registry Outcomes: Reflections From the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI-2D) Trial

Circulation Editors' Picks

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Complete Versus Incomplete Revascularization With Coronary Artery Bypass Graft or Percutaneous Intervention in Stable Coronary Artery Disease

In patients who have multivessel but stable coronary artery disease (CAD), the perceived advantages of complete revascularization (CR) over incomplete revascularization (IR) are intuitively logical and have been the impetus to perform CR whenever feasible. These advantages were suggested by early studies in patients with 3-vessel CAD who underwent coronary artery bypass graft (CABG) demonstrating a survival benefit of patients with CR compared with those with IR.1–4 Nonetheless, in practice, the variations in severity of the coronary anatomy as well as the patient’s clinical status often precludes CR resulting in a higher frequency of IR in patients with multivessel disease. For example, in the SYNTAX (SYNergy between PCI with TAXus and Cardiac Surgery) trial, patients randomized to percutaneous intervention (PCI)5 had CR in only 56.7% even when CR was intended and in Bypass Angioplasty Revascularization Investigation (BARI) this was 56%.6 A critical review of the literature demonstrates the complexity of the issues and poses several unanswered questions (Table 1). View this table: Table 1. Unanswered Questions In the current era of significantly improved medical therapy (primary and secondary prevention) of CAD as well as the increasing use of sophisticated invasive and noninvasive testing of the physiological significance of coronary artery stenoses, both surgeons and cardiologists have an arsenal of diagnostic tools at hand that may guide decisions in selecting revascularization strategies. This review provides a contemporary overview of the currently available literature in the field and proposes an evidence-based approach for patients with severe CAD and stable angina undergoing revascularization. ### The Missing Universal Definition The dilemma of comparing outcomes after CR and IR begins with the lack of universal definitions. There are considerable differences between complete/incomplete anatomic and functional/physiological revascularization. Ong and Serruys8 reviewed comprehensively past definitions of CR used in different trials (Table 2). View this table: Table 2. Summary of Definitions for Complete Revascularization …

Cuantificación del área miocárdica en riesgo: validación de puntuaciones angiográficas coronarias con métodos de resonancia magnética cardiovascular

Introduction and objectivesQuantification of myocardial area-at-risk after acute myocardial infarction has major clinical implications and can be determined by cardiovascular magnetic resonance. The Bypass Angioplasty Revascularization Investigation Myocardial Jeopardy Index (BARI) and Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) angiographic scores have been widely used for rapid myocardial area-at-risk estimation but have not been directly validated. Our objective was to compare the myocardial area-at-risk estimated by BARI and APPROACH angiographic scores with those determined by cardiovascular magnetic resonance. MethodsIn a prospective study, cardiovascular magnetic resonance was performed in 70 patients with a first successfully-reperfused ST-segment elevation acute myocardial infarction in the first week after percutaneous coronary intervention. Myocardial area-at-risk was obtained both by analysis of T2-short tau inversion recovery sequences and calculation of infarct endocardial surface area with late enhancement sequences. These results were compared with those of BARI and APPROACH scores. ResultsBARI and APPROACH showed a statistically significant correlation with T2-short tau inversion recovery for myocardial area-at-risk estimation (BARI, intraclass correlation coefficient=0.72; P<.001; APPROACH, intraclass correlation coefficient=0.69; P<.001). Better correlations were observed for anterior acute myocardial infarction than for other locations (BARI, intraclass correlation coefficient=0.73 vs 0.63; APPROACH, intraclass correlation coefficient=0.68 vs 0.50). Infarct endocardial surface area showed a good correlation with both angiographic scores (BARI, intraclass correlation coefficient=0.72; P<.001; with APPROACH, intraclass correlation coefficient=0.70; P<.001). ConclusionsBARI and APPROACH angiographic scores allow reliable estimation of myocardial area-at-risk in current clinical practice, particularly in anterior infarctions.Full English text available from:www.revespcardiol.org

Quantification of Myocardial Area at Risk: Validation of Coronary Angiographic Scores With Cardiovascular Magnetic Resonance Methods

Introduction and objectivesQuantification of myocardial area-at-risk after acute myocardial infarction has major clinical implications and can be determined by cardiovascular magnetic resonance. The Bypass Angioplasty Revascularization Investigation Myocardial Jeopardy Index (BARI) and Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) angiographic scores have been widely used for rapid myocardial area-at-risk estimation but have not been directly validated. Our objective was to compare the myocardial area-at-risk estimated by BARI and APPROACH angiographic scores with those determined by cardiovascular magnetic resonance. MethodsIn a prospective study, cardiovascular magnetic resonance was performed in 70 patients with a first successfully-reperfused ST-segment elevation acute myocardial infarction in the first week after percutaneous coronary intervention. Myocardial area-at-risk was obtained both by analysis of T2-short tau inversion recovery sequences and calculation of infarct endocardial surface area with late enhancement sequences. These results were compared with those of BARI and APPROACH scores. ResultsBARI and APPROACH showed a statistically significant correlation with T2-short tau inversion recovery for myocardial area-at-risk estimation (BARI, intraclass correlation coefficient=0.72; P<.001; APPROACH, intraclass correlation coefficient=0.69; P<.001). Better correlations were observed for anterior acute myocardial infarction than for other locations (BARI, intraclass correlation coefficient=0.73 vs 0.63; APPROACH, intraclass correlation coefficient=0.68 vs 0.50). Infarct endocardial surface area showed a good correlation with both angiographic scores (BARI, intraclass correlation coefficient=0.72; P<.001; with APPROACH, intraclass correlation coefficient=0.70; P<.001). ConclusionsBARI and APPROACH angiographic scores allow reliable estimation of myocardial area-at-risk in current clinical practice, particularly in anterior infarctions.

Multivessel Disease

Soon after the introduction of coronary artery bypass surgery, the completeness of revascularization became a matter of concern. Several early surgical studies confirmed the belief that better clinical outcomes were obtained when each and every angiographically visible stenosis was bypassed by a distal anastomosis.1,2 Similarly, among patients with multivessel disease treated with percutaneous coronary intervention (PCI), complete revascularization was found to provide a significant advantage over incomplete revascularization in terms of reintervention, myocardial infarction, and death.3,4 However, a careful analysis of surgically treated multivessel disease patients in the Bypass Angioplasty Revascularization Investigation (BARI) trial showed that 1 graft to any system other than the left anterior descending confers no long-term advantage over PCI and may actually be deleterious.5 Article see p 2613 More recently, the results of large surgical registries supported strategies of reasonably incomplete revascularization.6–8 In addition, the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) trial indicated that, in patients with multivessel disease, ≈ one third of angiographically significant stenoses were actually hemodynamically not significant.9 Stenting limited to stenoses with a fractional flow reserve (FFR) value below 0.80 yielded better clinical outcomes than stenting based on treating every visible lesion, introducing the concept of functionally complete rather than anatomically complete revascularization. Several factors contribute to the marked variability in prognostic value of incomplete revascularization reported. First, the definition of incomplete revascularization …

Impact of left ventricular function and the extent of ischemia and scar by stress myocardial perfusion imaging on prognosis and therapeutic risk reduction in diabetic patients with coronary artery disease: Results from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial

BackgroundThe Bypass Angioplasty Revascularization Investigation 2 Diabetes trial demonstrated similar long-term clinical effectiveness of revascularization (REV) and intensive medical (MED) therapy. Comparisons of post-intervention ischemic burden have not been explored but are relevant to treatment decisions. This study examined differences in 1-year stress myocardial perfusion SPECT (MPS) abnormalities by randomized treatment. MethodsMPS was performed in 1,505 patients at 1-year following randomization. MPS images were analyzed (masked to treatment) by a Nuclear Core Laboratory using a quantitative percent (%) of total, ischemic, and scarred myocardium. Cox proportional hazards models were used to estimate the relationship between MPS variables and trial endpoints. ResultsAt 1-year, nearly all REV patients underwent the assigned procedure; while 16% of those randomized to MED received coronary REV. Patients randomized to REV exhibited fewer stress perfusion abnormalities than MED patients (P < .001). CABG patients had more frequent ischemic and scarred myocardium encumbering ≥5% of the myocardium when compared to those receiving PCI. Patients randomized to MED had more extensive ischemia and the median % of the myocardium with perfusion abnormalities was lower following REV (3% vs 9%, P = .01). A total of 59% of REV patients had no inducible ischemia at 1-year compared to 49% of MED patients (P < .001). Within the CABG stratum, those randomized to MED had the greatest rate of ischemic (P = .032) and scarred (P = .017) perfusion abnormalities. At 1-year, more extensive and severe stress myocardial perfusion abnormalities were associated with higher 5-year rates of death and a combined endpoint of cardiac death or myocardial infarction (MI) rates (11.3%, 8.1%, 6.8%, for ≥10%, 5%-9.9%, and 1-4.9% abnormal myocardium at stress, respectively, P < .001). In adjusted models, selected MPS variables were significantly associated with an increased hazard of cardiac death or MI (hazard ratio = 1.11 per 5% increase in abnormal myocardium at stress, P = .004). ConclusionsPatient management strategies that focus on ischemia resolution can be useful to guide the efficacy of near-term therapeutic approaches. A 1-year post-therapeutic intervention myocardial perfusion scan provides important information regarding prognosis in stable CAD patients with diabetes.

Impact of Completeness of Revascularization on Long-Term Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus

Patients with diabetes have more extensive coronary disease than those without diabetes, resulting in more challenging percutaneous coronary intervention or surgical (coronary artery bypass graft) revascularization and more residual jeopardized myocardium. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial provided an opportunity to examine the long-term clinical impact of completeness of revascularization in patients with diabetes. This is a post hoc, nonrandomized analysis of the completeness of revascularization in 751 patients who were randomly assigned to early revascularization, of whom 264 underwent coronary artery bypass graft surgery and 487 underwent percutaneous coronary intervention. The completeness of revascularization was determined by the residual postprocedure myocardial jeopardy index (RMJI). RMJI is a ratio of the number of myocardial territories supplied by a significantly diseased epicardial coronary artery or branch that was not successfully revascularized, divided by the total number of myocardial territories. Mean follow-up for mortality was 5.3 years. Complete revascularization (RMJI=0) was achieved in 37.9% of patients, mildly incomplete revascularization (RMJI >0≤33) in 46.6%, and moderately to severely incomplete revascularization (RMJI >33) in 15.4%. Adjusted event-free survival was higher in patients with more complete revascularization (hazard ratio, 1.14; P=0.0018). Patients with type 2 diabetes mellitus and less complete revascularization had more long-term cardiovascular events. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00006305.

Myocardial perfusion imaging: a plus for coronary risk classification in diabetics

Type 2 diabetes mellitus is the most common form of diabetes worldwide (>90%). Long-term complications of diabetes include microvascular and macrovascular damage. Life expectancy of patients with diabetes remains substantially shorter than that of individuals without diabetes, mainly because of coronary heart disease (CHD) [1]. However, CHD risk in patients with diabetes is highly variable and difficult to stratify by conventional clinical markers [2, 3]. Moreover, the early identification of CHD in diabetics is difficult due to its often silent or atypical presentation in this population. As a result, CHD in diabetics may be diagnosed several years after its onset, when the disease is in an advanced stage, frequently in the form ofmyocardial infarction (MI) or sudden cardiac death. To improve outcomes, common CHD risk factors should be assessed at least annually, along with the presence of microor macroalbuminuria, and be actively managed [4, 5]. The increasing prevalence of diabetes and the associated high CHD risk raises the question as to the need to develop noninvasive approaches to detect the patients with diabetes at the highest risk of CHD. This strategy could identify higher risk diabetics in whom coronary revascularization may improve the outcome beyond that achieved by currently recommended medical management. Stress/rest myocardial perfusion imaging (MPI) is effective in detecting CHD and predicting adverse cardiac events in diabetic patients [6, 7]. Nevertheless, the clinical utility of MPI in diabetics is debated due to the small number of prospective and outcome studies, along with some epidemiological and cost-effectiveness data. It has been reported that routine screening of asymptomatic diabetics who have a normal ECG does not have clinical benefit and that cardiac outcomes are essentially equal (and very low) in screened and unscreened patients (despite abnormal MPI in >20% of these patients) [8]. In addition, according to the large multicentre Bypass Angioplasty Revascularization Investigation 2 Diabetes trial (BARI 2D), optimal intensive medical therapy provides equal outcomes to revascularization in patients with diabetes [9]. In this randomized trial, only patients who had undergone coronary bypass surgery had significantly reduced major cardiac events, compared with those assigned in the intensive medical therapy group, but no difference in mortality was recorded. Therefore, only those diabetics with evidence of myocardial ischaemia and extensive multivessel disease would benefit from prompt surgical revascularization, mainly because of a lower rate of nonfatal MI. It is noteworthy that the majority of the patients enrolled had symptoms and all of them had stable CHD [9]. There is also some evidence that silent myocardial ischaemia may reverse over time with optimized medical treatment, adding to the controversy concerning aggressive screening strategies [10]. Finally, it has been reported that even asymptomatic diabetics with intermediate/high CHD risk have a low annual cardiac event rate (<1%), which is not affected by routine screening for inducible ischaemia [11]. Since screening for CHD in asymptomatic patients does not improve outcomes as long as CHD risk factors are treated, it is not routinely recommended by professional organizations or guidelines for appropriate use of cardiac A. Flotats Nuclear Medicine Department, Universitat Autonoma de Barcelona, Barcelona, Spain