title: Appropriate revascularization in stable angina: lessons from the BARI 2D trial.
abstract: BACKGROUND
  The 2012 Guidelines for Diagnosis and Management of Patients with Stable Ischemic Heart Disease recommend intensive antianginal and risk factor treatment (optimal medical management [OMT]) before considering revascularization to relieve symptoms. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial randomized patients with ischemic heart disease and anatomy suitable to revascularization to (1) initial OMT with revascularization if needed or (2) initial revascularization plus OMT and found no difference in major cardiovascular events. Ultimately, however, 37.9% of the OMT group was revascularized during the 5-year follow-up period.
  
  
  METHODS
  Data from the 1192 patients randomized to OMT were analyzed to identify subgroups in which the incidence of revascularization was so high that direct revascularization without a trial period could be justified. Multivariate logistic analysis, Cox regression models of baseline data, and a landmark analysis of participants who did not undergo revascularization at 6 months were constructed.
  
  
  RESULTS
  The models that used only data available at the time of study entry had limited predictive value for revascularization by 6 months or by 5 years; however, the model incorporating severity of angina during the first 6 months could better predict revascularization (C statistic = 0.789).
  
  
  CONCLUSIONS
  With the possible exception of patients with severe angina and proximal left anterior descending artery disease, this analysis supports the recommendation of the 2012 guidelines for a trial of OMT before revascularization. Patients could not be identified at the time of catheterization, but a short period of close follow-up during OMT identified the nearly 40% of patients who underwent revascularization.
authors.affiliation: Division of Cardiology, Washington University, St. Louis, Missouri, USA. Electronic address: rkrone@dom.wustl.edu.
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Krone
authors.affiliation: Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Althouse
authors.affiliation: Mount Sinai Saint Luke's Hospital, New York, New York, USA.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Tamis-Holland
authors.affiliation: Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Venkitachalam
authors.affiliation: Department of Cardiology, Hospital de Especialidades, Centro Medico La Raza, IMSS, Mexico City, Mexico.
authors.forename: Arturo
authors.initials: A
authors.lastname: Campos
authors.affiliation: Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors.forename: Alan
authors.initials: A
authors.lastname: Forker
authors.affiliation: Boston University and Boston Medical Center, Boston, Massachusetts, USA.
authors.forename: Alice K
authors.initials: AK
authors.lastname: Jacobs
authors.affiliation: Department of Cardiology, Hospital de Especialidades, Centro Medico La Raza, IMSS, Mexico City, Mexico.
authors.forename: Salvador
authors.initials: S
authors.lastname: Ocampo
authors.affiliation: The University of Toronto, Toronto, Ontario, Canada.
authors.forename: George
authors.initials: G
authors.lastname: Steiner
authors.affiliation: Division of Cardiology, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
authors.forename: Francisco
authors.initials: F
authors.lastname: Fuentes
authors.affiliation: Heart and Vascular Catheterization Laboratories, Nanticoke Memorial Hospital, Seaford, Delaware, USA; New York University, New York, New York, USA.
authors.forename: Ivan R
authors.initials: IR
authors.lastname: Pena Sing
authors.affiliation: Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: Maria Mori
authors.initials: MM
authors.lastname: Brooks
mesh_terms: D000787:Angina Pectoris / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D001786:Blood Glucose / Q000378:metabolism; D017023:Coronary Angiography; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000150:complications*; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin