<International Circulation>:ccording to a subgroup analysis from the multinational SYNTAX study recently published in JACC， for patients with diabetes and complex multivessel coronary artery disease， the risk of repeat vascularization within one year is elevated 3-fold after percutaneous coronary intervention (PCI) compared to surgery. Can you comment on this conclusion?
Donald E. Cutlip ：I don’t think this is surprising. Diabetes is a major risk factor for restenosis for both bare metal and drug-eluting stents. In these high risk patients with multivessel disease these risks are even higher. The real question is whether these risks translate to differences in mortality or myocardial infarction and possibly whether the risks might be stratified by lesion complexity (Syntax score) as was observed for the overall SYNTAX population.
<International Circulation>:Some recent reports also support the traditional viewpoint that patients with diabetes and cardiovascular disease are not good candidates for interventional therapeutics. Should we rule out interventional management in this population?
Donald E. Cutlip ：This is a very important question. The FREEDOM trial is attempting to answer this question specifically in patients with diabetes and multivessel CAD. There are a number of reasons why patients with diabetes and extensive disease who require revascularization may do better with bypass surgery. The most important of these is the protection by bypass from impact of disease progression， which is accelerated in patients with diabetes.
<International Circulation>: What is the appropriate management strategy for patients with diabetes and cardiovascular disease who are in need of revascularization?
Donald E. Cutlip ：For 1-2 vessel disease that can be approached with high success by stenting and is associated with definite ischemia， I think drug-eluting stenting is a reasonable strategy. I think for diffuse disease， especially if the proximal left anterior descending is involved， then bypass surgery is probably preferred. We must also keep in mind that， similar to patients without diabetes， medical therapy is also a reasonable initial strategy. In my opinion， if definite large territories of ischemia are present， revascularization is a better option. As shown in BARI-2D， however， an initial medical strategy is reasonable， but there is high rate of eventual requirement for revascularization.
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