Diabetes mellitus and multivessel coronary artery disease: an ongoing battle for an ideal treatment strategy

Already in the late 90s, Haffner et al. introduced diabetes mellitus (DM) as a coronary artery disease (CAD) equivalent condition (1). Several more recent similar investigations confirmed those earlier findings (2). Despite broad developments in pharmacotherapy and revascularizations techniques, the combination of DM and CAD still represents a major challenge for the clinician. The clinical guidelines advocate intensive medical therapy with lifestyle and pharmacologic interventions as the initial approach in patients with stable CAD (3,4). Contemporary, percutaneous coronary intervention (PCI) has become one of the most frequently performed therapeutic intervention in medicine. Revascularization for significant narrowed coronary lesions has been shown to improve ischemic endpoints (5). Whether optimal conservative therapy alone or in combination with revascularization strategies in stable CAD leads to more anti-ischemic benefit has been investigated extensively. In patients with DM, finding optimal treatment strategies are more crucial in view of the fact of their poor prognosis in comparison with non-diabetics (6,7). Multivessel CAD in patients with DM has been evaluated in the FREEDOM trial (8,9). Most patients had very extensive disease and CABG was superior regardless SYNTAX score. Event curves started to diverge beyond 2-years after randomization. Insulin treated patients fared worse than those not treated with insulin. Cardiovascular events were generally concordant to the main study in the insulin treatment subgroups.