Clinical implications of the BARI 2D and COURAGE trials of coronary artery disease.

The results of the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) and Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) clinical trials raise important questions about the prevention and treatment of coronary heart disease among type 2 diabetics and nondiabetics. The BARI 2D and COURAGE trials showed that pharmacological therapy is as effective as surgery or angioplasty, because of the incidence of total mortality and cardiovascular disease events. The results are consistent with the clinical trials of lipid-lowering, antihypertensive therapy. The efficacy of lowering glycohemoglobin below 7% or benefits of specific glucose-lowering drugs is still unresolved. The BARI 2D trial focused on more advanced atherosclerotic disease. An important question is whether newly incident diabetics should be screened for subclinical atherosclerosis and treated aggressively with pharmacological therapy as in the BARI 2D trial. We are still uncertain whether raising high-density lipoprotein cholesterol will provide further benefit in reducing coronary heart disease. Better measurement of plaque morphology, determinants of hypercoagulable status, and drugs to reduce thrombosis and plaque are of high priority. Longer follow-up of the BARI 2D and COURAGE trials will provide important information about the risks of cardiovascular disease events and disability. It will be important but difficult to translate the results of the trials to community practice under the current health care system.