title: Impact of left ventricular function and the extent of ischemia and scar by stress myocardial perfusion imaging on prognosis and therapeutic risk reduction in diabetic patients with coronary artery disease: results from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial.
abstract: BACKGROUND
  The Bypass Angioplasty Revascularization Investigation 2 Diabetes trial demonstrated similar long-term clinical effectiveness of revascularization (REV) and intensive medical (MED) therapy. Comparisons of post-intervention ischemic burden have not been explored but are relevant to treatment decisions. This study examined differences in 1-year stress myocardial perfusion SPECT (MPS) abnormalities by randomized treatment.
  
  
  METHODS
  MPS was performed in 1,505 patients at 1-year following randomization. MPS images were analyzed (masked to treatment) by a Nuclear Core Laboratory using a quantitative percent (%) of total, ischemic, and scarred myocardium. Cox proportional hazards models were used to estimate the relationship between MPS variables and trial endpoints.
  
  
  RESULTS
  At 1-year, nearly all REV patients underwent the assigned procedure; while 16% of those randomized to MED received coronary REV. Patients randomized to REV exhibited fewer stress perfusion abnormalities than MED patients (P < .001). CABG patients had more frequent ischemic and scarred myocardium encumbering ≥ 5% of the myocardium when compared to those receiving PCI. Patients randomized to MED had more extensive ischemia and the median % of the myocardium with perfusion abnormalities was lower following REV (3% vs 9%, P = .01). A total of 59% of REV patients had no inducible ischemia at 1-year compared to 49% of MED patients (P < .001). Within the CABG stratum, those randomized to MED had the greatest rate of ischemic (P = .032) and scarred (P = .017) perfusion abnormalities. At 1-year, more extensive and severe stress myocardial perfusion abnormalities were associated with higher 5-year rates of death and a combined endpoint of cardiac death or myocardial infarction (MI) rates (11.3%, 8.1%, 6.8%, for ≥ 10%, 5%-9.9%, and 1-4.9% abnormal myocardium at stress, respectively, P < .001). In adjusted models, selected MPS variables were significantly associated with an increased hazard of cardiac death or MI (hazard ratio = 1.11 per 5% increase in abnormal myocardium at stress, P = .004).
  
  
  CONCLUSIONS
  Patient management strategies that focus on ischemia resolution can be useful to guide the efficacy of near-term therapeutic approaches. A 1-year post-therapeutic intervention myocardial perfusion scan provides important information regarding prognosis in stable CAD patients with diabetes.
authors.affiliation: Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Rd NE, Room 529, Atlanta, GA 30306, USA. lshaw3@emory.edu
authors.forename: Leslee J
authors.initials: LJ
authors.lastname: Shaw
authors.forename: Manuel D
authors.initials: MD
authors.lastname: Cerqueira
authors.forename: Maria M
authors.initials: MM
authors.lastname: Brooks
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Althouse
authors.forename: Veronica V
authors.initials: VV
authors.lastname: Sansing
authors.forename: George A
authors.initials: GA
authors.lastname: Beller
authors.forename: Rodica
authors.initials: R
authors.lastname: Pop-Busui
authors.forename: Raymond
authors.initials: R
authors.lastname: Taillefer
authors.forename: Bernard R
authors.initials: BR
authors.lastname: Chaitman
authors.forename: Raymond J
authors.initials: RJ
authors.lastname: Gibbons
authors.forename: Jaekyeong
authors.initials: J
authors.lastname: Heo
authors.forename: Ami E
authors.initials: AE
authors.lastname: Iskandrian
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D002921:Cicatrix / Q000503:physiopathology; D003327:Coronary Disease / Q000503:physiopathology* / Q000628:therapy*; D048909:Diabetes Complications / Q000503:physiopathology; D003920:Diabetes Mellitus / Q000503:physiopathology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000473:pathology*; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D009206:Myocardium / Q000473:pathology; D011379:Prognosis; D016016:Proportional Hazards Models; D012306:Risk; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods; D016277:Ventricular Function, Left