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| AATS/NHLBI: Cardiothoracic Surgery Exploring Collaborative Clinical Research Opportunities |
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Title and Author Aging Populations and Co-morbidities: DIABETES MELLITUSRobert L. Frye, MD Abstract Clinical outcomes are worse for patients with diabetes mellitus(DM) compared to those without DM in all clinical settings. In particular those on insulin are at highest risk for death or myocardial infarction(MI). The original Bypass Angioplasty Revascularization Investigation(BARI) highlighted the striking mortality over 10 years for diabetic patients randomized to CABG; mortality with PTCA in diabetic patients was even worse. BARI 2D was designed to test two treatment strategies in patients with Type 2 DM; a 2X2 design was used to test simultaneously if mortality/MI is reduced by early revascularization compared to delayed or no revascularization and controlling glycemia with insulin sensitizing drugs compared to insulin providing drugs. . All patients were stable and had clinically indicated coronary arteriography; those eligible for randomization did not require PCI or CABG to control symptoms. Prior to randomization patients were selected for PCI or CABG with the expectation that those with the most extensive disease would be selected for CABG. The randomization was stratified on the basis of the procedure selected. In the overall analysis no advantage of early revascularization or insulin sensitizing strategies was demonstrated. However when analyzed by strata, those with the highest risk (i.e. those in the CABG stratum) showed a benefit with early CABG in the combined endpoint of death, MI and stroke. The major benefit was in reduction of spontaneous MI unrelated to procedures.This benefit was enhanced by an insulin sensitizing strategy. Management of glucose in the perioperative period has been a challenge with strong opinions but few randomized trials to test different strategies. In BARI 2D general guidelines were provided for glucose control in the perioperative period but did not require tight control with intravenous insulin. Furnary has published compelling observational data to suggest a benefit from aggressive control of glucose in reducing mortality after CABG. Others have found potential adverse effects of intensive control of glucose, including the recent ACCORD trial in the general population of patients with DM. Key Research Gap Requiring NHLBI Leadership
Key Citations 1: The BARI 2D Investigators. A randomized trial of therapies for Type 2 DM NEJM 2009;360:250325152: Furnary AP, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. Journal of thor and Cardiovascular Surgery 2003;125:1007-21 3: Sato H, et al. The association of preoperative glycemic control, intraoperative insulin sensitivity, and outcomes after cardiac surgery. Journal of Clinical Endocrinology and Metabolism 2010;95;4338-4344. |
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Copyright © 2012 American Association for Thoracic Surgery
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All rights reserved. IMPORTANT REMINDER: The preceding information is intended only to provide
general guidance and not as a definitive basis for diagnosis or treatment in any particular case.
It is very important that you consult a doctor about any specific medical problem or question.