Drug eluting stents for patients with diabetesBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5828 (Published 12 September 2012) Cite this as: BMJ 2012;345:e5828
All rapid responses
I would like to thank Dr Jeffrey for his interest and comment on the editorial. Indeed, coronary revascularisation in patients with diabetes is a contemporary subject of great interest. First, to clarify, the first sentence quoted was incomplete. It referred to the fact that surgical revascularisation was superior to coronary stenting. It did not compare coronary artery bypass grafting with optimal medical therapy, as it was implied.
In the section on Diabetes in the European Guidelines on Myocardial Revascularization(1), only BARI-2D was cited regarding the indication for myocardial revascularisation (9.1.1). The “Take Home Message” from the same Guideline recommended coronary revascularisation for those with diabetes and extensive disease. It then proceeded to recommend how to choose between the 2 strategies. Patients are likely to benefit from a multi-disciplinary approach. Moreover, in a recent review on coronary revascularisation in patients with diabetes(2), the authors suggested that those without high risk characteristics, “medical therapy may be a valuable initial strategy.” Therefore, it is not unreasonable to maintain the optimal medical treatment should remain as the core approach, regardless of revascularisation strategy. With improved outcomes in patients with diabetes treated with second- and third-generation drug eluting stents, as shown in the accompanying paper, the efficacy compared with coronary artery bypass grafting would need to be re-evaluated.
1. Guidelines on myocardial revascularization. The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-thoracic Surgery (EACTS). Eur Heart J 2010;31:2501-55.
2. Roffi M, Angiolillo DJ, Kappetein AP. Current concepts on coronary revascularization in diabetic patients. Eur Heart J 2011; 32:2748-57.
Competing interests: As stated in the editorial.
In his editorial(1) on drug eluting stents for patients with diabetes, I was particularly disappointed in Dr Mak’s conclusion that “optimal medical treatment will probably remain the core treatment for patients with diabetes”. In the opening paragraph, he acknowledges the superior results of surgical revascularisation with better long term survival and freedom from further revascularisation in patients with diabetes. I would suggest that the results of surgery do not require further clarification but the use of stenting in patients with multivessel disease and diabetes is unproven. If patients being considered for revascularisation including diabetics were formally discussed at a multidisciplinary meeting comprising informed surgeons and interventionists as suggested in the guideline(2) published jointly by EACTS and ESC then we may be able to progress beyond the “occulo-stent reflex” so highly developed in interventionists and provide a superior long term outcome for our diabetic patients with angina.
1 BMJ 2012;345:e5828
2 Guidelines on myocardial revascularization
The Task Force on Myocardial Revascularization of the European
Society of Cardiology (ESC) and the European Association for
Cardio-Thoracic Surgery (EACTS) European Heart Journal (2010) 31, 2501–2555
Competing interests: No competing interests