Optimal care of patients with type 2 diabetes mellitus and coronary artery disease

Although cardiovascular mortality rates for the general population have declined during the past several decades, mortality among individuals with diabetes mellitus has increased. Given that the prevalence of type 2 diabetes is increasing dramatically and that current treatment strategies appear inadequate, there is a critical need for well-designed studies to address treatment of coronary artery disease in patients with diabetes to help guide clinical decision making in this setting. The Bypass Angioplasty Revascularization Investigation (BARI)–2D focuses on 2 specific treatment issues in the management of patients with type 2 diabetes. The first issue is the incremental value of early use of coronary revascularization procedures, and the second is the value of treating with an insulin-sensitizing agent versus an insulin-providing therapy. It is essential to determine whether treatment to enhance insulin sensitivity improves cardiovascular survival. Data indicate that outcomes of patients with diabetes and myocardial infarction are improved by administration of insulin or a regimen of glucose, insulin, and potassium (GIK). The Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study showed that administration of an insulin infusion followed by subcutaneous insulin therapy for ≥3 months improved the long-term prognosis of diabetic patients with acute myocardial infarction. However, there appears to be a lack of acceptance of these interventions by health care providers. Clinical trials of GIK and insulin sensitizers are needed to define further the optimal treatment of patients with type 2 diabetes and cardiovascular disease.