Silent Myocardial Ischemia in Patients With Diabetes Mellitus

It is well established that coronary artery disease is a major complication of diabetes mellitus, representing the ultimate cause of death in more than half of all patients with this disease.1 Clinicopathological correlations, as well as several angiographic studies, suggest that diabetic patients have more extensive atherosclerotic disease, affecting the coronary arteries in particular.2 3 4 5 6 Furthermore, myocardial infarction in diabetic patients usually is more extensive and more severe than in nondiabetic patients.7 8 9 The long-term survival rate after acute myocardial infarction among diabetic patients is also lower than that among nondiabetic patients.10 In fact, the 5-year survival rates for diabetic patients after the first major coronary event have been found to be 38% and only 25% for those with subsequent events, compared with the corresponding figures in nondiabetic patients of 75% and 50%, respectively.7 8 Recently, patients with diabetes mellitus and multivessel coronary disease were found to have a significantly higher mortality rate with PTCA than with CABG.11 In fact, on September 21, 1995, the National Heart, Lung, and Blood Institute released a clinical alert to US physicians regarding the 5-year mortality results of patients with diabetes mellitus in BARI.11 BARI includes 1829 patients with multivessel coronary artery disease who were randomly assigned to either CABG or PTCA. In this study, the review of available 5-year mortality data demonstrated that patients with diabetes who were on insulin or oral therapy have a 35% mortality rate with PTCA compared with the 19% mortality rate with CABG.11 Diabetic patients also have a higher rate of infarction and a greater need for additional revascularization procedures, probably because of early restenosis and late progression of coronary disease.12 In this regard, further studies should be performed to assess whether or not stent …