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Is coronary artery bypass grafting the treatment of choice for diabetic patients with multivessel disease? No

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c6975 (Published 13 December 2010) Cite this as: BMJ 2010;341:c6975
  1. Iqbal Malik, consultant cardiologist1
  1. 1International Centre for Circulatory Health Cardiovascular Sciences and Renal Institute, Imperial College Healthcare NHS Trust, London W2 1NY, UK
  1. Iqbal.malik{at}imperial.nhs.uk

Nicholas Brooks (doi:10.1136/bmj.c6961) argues that CABG provides more permanent relief for diabetic patients, but Iqbal Malik thinks that the evidence is less clear cut

Patients with diabetes mellitus have a twofold to fourfold increased risk of cardiovascular events compared with those without diabetes.1 2 The question is whether coronary artery bypass grafting (CABG) offers specific benefit that cannot be gained by less invasive percutaneous coronary intervention (PCI) with or without drug eluting stents, or even best medical therapy? I believe the answer is no.

Best medical therapy

Outcomes in diabetes are worse in patients with high haemoglobin A1c concentrations. A meta-analysis of five randomised trials confirmed that lowering haemoglobin A1c below 7% resulted in a 17% reduction in myocardial infarction but had no effect on overall mortality.3 Statins and aspirin have been shown to reduce risk of coronary heart disease, as has the rigorous control of blood pressure.4 5

Once coronary heart disease is established, drugs remain the mainstay of treatment. The BARI-2D study looked at 2368 patients with diabetes and stable symptoms. Angiography was used to determine whether revascularisation with PCI or CABG was most suitable for each participant based on the …

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