Department of Cardiology, Liverpool Hospital, Southwestern Clinical School, University of New South Wales, Elizabeth St, Sydney, New South Wales, Australia.
Clin Ther. 2013 Aug;35(8):1069-75. doi: 10.1016/j.clinthera.2013.07.427.
Diabetes mellitus (DM) is a powerful independent risk factor for multivessel, diffuse coronary artery disease (CAD). The optimal coronary revascularization strategy in DM is not clearly defined, but past trials have suggested an advantage for coronary artery bypass grafting (CABG). Recently, the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial found patients randomized to CABG had lower rates of death and myocardial infarction (MI) compared with those randomized to percutaneous coronary intervention (PCI).
This article reviews the contemporary management of patients with DM presenting with acute coronary syndromes, particularly ST-elevation MI, in the post-FREEDOM era.
We undertook a comprehensive review of published literature addressing trials in this field performed to address current knowledge both in the pre- and post-FREEDOM era.
The implications of FREEDOM for patients with acute coronary syndrome are that CABG provides a significant benefit, compared with PCI with drug-eluting stents, to patients with DM and multivessel coronary artery disease; and that patients similar to those enrolled in FREEDOM should receive CABG in preference to PCI. The relevance of FREEDOM's findings to the large proportion of patients who would not meet inclusion criteria-including patients with an acute coronary syndrome undergoing an early or emergent invasive strategy, remains uncertain.
FREEDOM's outcomes have generated uncertainty regarding best practice once thrombolysis in myocardial infarction grade 3 flow is re-established in patients with DM and multivessel disease. Current interventional guidelines recommend optimally treating the culprit artery; however, decisions made at the time of revascularization influence future revascularization strategies, particularly stent choice and resultant P2Y12 receptor antagonist therapy. The preferred method for future revascularization may be questioned if the patient's residual coronary stenoses do not, post-PCI, meet the FREEDOM inclusion criteria, or where the left anterior descending artery is the infarct-related artery, and after left anterior descending artery PCI the patient would not receive an internal mammary graft. The management of residual disease and the preferred (further) revascularization strategy needs to be tested in an appropriately powered randomized trial.
The optimal revascularization strategy in patients with acute coronary syndrome, diabetes, and multivessel disease, in particular those with ST elevation, is unclear, and not guided by level A (or B) evidence. Currently CABG is favored over PCI, and an individually tailored, collaborative approach, guided by a multidisciplinary heart team, should be employed.
糖尿病（DM）是多支弥漫性冠状动脉疾病（CAD）的强大独立危险因素。DM 患者的最佳冠状动脉血运重建策略尚不清楚，但以往的试验表明冠状动脉旁路移植术（CABG）有优势。最近，糖尿病患者冠状动脉血运重建评估的未来研究：多血管疾病的最佳治疗（FREEDOM）试验发现，与随机接受经皮冠状动脉介入治疗（PCI）的患者相比，随机接受 CABG 的患者死亡率和心肌梗死（MI）发生率较低。
本文回顾了 DM 患者急性冠状动脉综合征（特别是 ST 段抬高型心肌梗死）的当代治疗方法，特别是在 FREEDOM 试验之后。
我们对该领域发表的文献进行了全面综述，以解决 FREEDOM 试验前后的当前知识。
FREEDOM 对急性冠状动脉综合征患者的影响是，与药物洗脱支架 PCI 相比，CABG 为多支血管 CAD 合并 DM 的患者提供了显著获益；并且，与 FREEDOM 试验入组患者相似的患者，应该接受 CABG 而不是 PCI。FREEDOM 研究结果对大多数不符合纳入标准的患者（包括接受早期或紧急侵入性策略的急性冠状动脉综合征患者）的相关性仍不确定。
一旦 DM 合并多支血管疾病患者溶栓后达到心肌梗死 3 级血流，FREEDOM 的结果就引发了对最佳治疗实践的不确定性。目前的介入指南建议最佳治疗罪犯血管；然而，血运重建时的决策会影响未来的血运重建策略，特别是支架的选择和由此产生的 P2Y12 受体拮抗剂治疗。如果 PCI 后患者的残余冠状动脉狭窄不符合 FREEDOM 纳入标准，或者前降支是梗死相关动脉，并且在前降支 PCI 后患者不会接受内乳动脉移植物，那么可能会对未来的血运重建方法提出质疑。需要在一项具有适当效力的随机试验中检验残余疾病的管理和首选（进一步）血运重建策略。
急性冠状动脉综合征、糖尿病和多支血管疾病患者的最佳血运重建策略尚不清楚，也没有 A 级（或 B 级）证据指导。目前，CABG 优于 PCI，应该采用个体化、协作的方法，由多学科心脏团队指导。
