Management of coronary artery disease: Therapeutic options in patients with diabetes

OBJECTIVES The aim of this review is to discuss the particularities of coro nary artery disease (CAD), the effect of intensive medical management and t he outcome of percutaneous and surgical revascularization in patients with diabetes mellitus (DM). BACKGROUND CAD represents the leading cause of death in patients with DM. N umerous clinical, biological and angiographic risk factors have been shown to be associated with CAD in diabetic patients. METHODS Metabolic abnormalities in patients with DM including insulin resis tance, hyperglycemia and dyslipidemia are briefly discussed. Then the poten tial roles of medical management and of percutaneous and surgical coronary revascularization are more extensively reviewed. RESULTS More vigorous control of hyperglycemia, hyperlipidemia, hypertensio n and other risk factors may be of crucial importance for risk reduction. D espite remarkable progress in recent years, the choice of a coronary revasc ularization strategy remains a challenge in these patients. Diabetic patien ts with CAD are predisposed to higher cardiovascular events after balloon a ngioplasty. Whether stenting and new antiplatelet drugs improve the results of percutaneous revascularization in this population needs further evaluat ion. The superiority of the surgical approach is also not definitely establ ished. Therefore, many aspects of coronary revascularization are still uncl ear in these patients. CONCLUSIONS The results of ongoing randomized trials comparing multiple cor onary stents to bypass surgery will likely provide some answers to our ques tions and additional randomized trials evaluating intensive diabetic contro l with or without coronary revascularization are needed to determine the be st therapeutic approach in these patients. (C) 2000 by the American College of Cardiology.