Current perspectives on coronary revascularization in the diabetic patient

In the last few decades, the increase in the prevalence of type 2 diabetes mellitus has reached epidemic proportions in the Western world. A similar, though delayed, pattern is seen in developing countries. Chronic hyperglycemia, dyslipidemia, and insulin resistance have been associated with an accelerated form of atherogenesis, characterized by a prothrombotic state, enhanced inflammation, and endothelial dysfunction. Diabetic patients undergoing coronary revascularization have worse outcomes compared to nondiabetic individuals, both in the setting of percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG). Though subgroup analyses of randomized trials and registries have suggested that CABG is superior to PCI in diabetic patients with multivessel disease, the results of ongoing large randomized trials focusing for the first time on diabetic patients should be awaited in order to establish the optimal revascularization strategy in this patient population. In the setting of acute coronary syndromes, diabetic patients are also at high short- and long-term risk for cardiovascular morbidity and mortality. Despite deriving greater benefit than nondiabetic counterparts from aggressive management, including early revascularization and potent platelet inhibition, diabetic patients are often undertreated.