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Angina severity, therapeutic choices and outcome in patients with diabetes mellitus

      In this issue of Atherosclerosis, Mancini et al. [
      • Mancini G.B.J.
      • Boden W.E.
      • Brooks M.M.
      • et al.
      Impact of treatment strategies on outcome in patients with stable coronary artery disease and type 2 diabetes mellitus according to presenting angina severity: a pooled analysis of three federally funded randomized trials.
      ] present the results of a pooled analysis of three randomized clinical trials spanning the past 2 decades, on patients with stable obstructive coronary artery disease amenable to revascularization, randomized to either optimal medical therapy (OMT), percutaneous interventions (PCI) plus OMT or coronary artery by-pass surgery (CABG) plus OMT. Two of the randomized trials enrolled patients with diabetes mellitus type 2 only [
      • Farkouh M.E.
      • Domanski M.
      • Sleeper L.A.
      • et al.
      FREEDOM Trial Investigators. Strategies for multivessel revascularization in patients with diabetes.
      ,
      • BARI 2D Study Group
      • Frye R.L.
      • August P.
      • Brooks M.M.
      • et al.
      A randomized trial of therapies for type 2 diabetes and coronary artery disease.
      ] and one enrolled both diabetic and non-diabetic patients [
      • Boden W.E.
      • O'Rourke R.A.
      • Teo K.K.
      • et al.
      COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease.
      ]. The authors examined an interesting question: does the severity of presenting angina affect the outcome (hard events, revascularization post-randomization and angina at 1 year) of patients with diabetes mellitus? Of note, 15% of patients randomized in these trials did not have any angina at the time of randomization. Surprisingly, after multivariable adjustment for several confounders, angina was not a predictor of outcome and diabetic patients with any severity of baseline angina, or lack thereof, appeared to be better served by CABG + OMT than either of the 2 alternatives. Severity of baseline angina was only significantly associated with the need for revascularization during long-term follow-up. Additionally, a small advantage of PCI + OMT over OMT alone was the reduced need for revascularization after randomization.

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