International Diabetes: BARI 2D study shows that intensive medical therapy based on prompt revascularization therapy has no advantage in reducing the main composite endpoint events (death or major cardiovascular events)， what do you think about the result?

Prof. Sheryl F. Kelsey：There were no  five year mortality differences between prompt revascularization and delayed/no revascularization or between an insulin sensitizing strategy and an insulin providing strategy so all of these strategies are safe. Note that all patients received intensive medical therapy to control glycemia， blood pressure， lipids and angina. The  five year mortality rate overall was 12%. For patients with this deadly duo of heart disease and diabetes， this low rate demonstrates that currently available medications， when used intensively， are remarkably effective.

Prof. Sheryl F. Kelsey：目前还没有研究表明立即血运重建和延迟/无血运重建之间的五年死亡率差异；也没有关于胰岛素增敏（IS）与胰岛素替代（IP）策略的五年死亡率差异，所以这些治疗方法都是安全的。值得注意的是，所有患者都采用强化药物治疗以控制血糖、血压、血脂以及心绞痛。五年总体死亡率为12％，对于糖尿病合并有心血管疾病的患者，如此低的死亡率表明目前所使用的药物，尤其是药物强化治疗是非常有效的。

International Diabetes: Compared with medical treatment， CABG can be added to reduce non-fatal major cardiovascular events， especially for the acceptance of insulin-sensitizing treatment of patients， however， the basis of drug therapy in addition to PCI， and death or the incidence of non-fatal major cardiovascular events can not be reduced. In your opinion， what is it’s mechanism?

Prof. Sheryl F. Kelsey：BARI 2D showed for patients with more extensive coronary disease who were suitable for coronary artery bypass graft surgery， that surgery compared with medical therapy alone resulted in a lower rate of major cardiovascular events， primarily a lower rate of myocardial infarction. Use of angioplasty compared with medical therapy did not result in lower event rates.  My clinical colleagues speculate that that the reason for this is that bypass surgery achieves complete revascularization， that is all the blockages are circumvented.  Often with angioplasty some but not all of the blockages are opened.
International Diabetes: Whether the BARI 2D study suggests that insulin-sensitizing drugs such as rosiglitazone may be useful for some patients with diabetes， especially for those who received bypass surgery?

Prof. Sheryl F. Kelsey：BARI 2D研究显示，对于多支血管病变的患者更适合CABG，与药物单独治疗相比，加用CABG患者主要心血管事件的发生率更低，尤其是心肌梗死，然而加用PCI患者的心血管事件的发生率则不会降低。我们推测其原因可能是因为CABG可获得完全心肌血运重建，消除了所有的血管障碍物，但部分PCI患者的血管却不是完全畅通的。

We did not set out to investigate whether insulin sensitizing strategy added to bypass surgery prevented major cardiovascular events.  However the observation of a low event rate in that group will prompt further study.  While there was not a statistically significant difference  in major cardiovascular events between the insulin sensitizing and the insulin providing  groups there were some other advantages  to the insulin sensitizing strategy. Typically patients in the insulin sensitizing strategy received rosiglitazone and metformin. On average these patients had fewer hypoglycemic episodes， achieved a lower HbA1c level and had less adverse change in weight and waist circumference.

该研究中我们没有专门研究是否添加胰岛素增敏剂＋CABG可有效预防主要心血管事件的发生，但胰岛素增敏剂＋CABG组中较低的心血管事件发生率促使我们对此进行更加深入的研究。虽然胰岛素增敏组与胰岛素替代组在主要心血管事件方面无统计学差异，但胰岛素增敏组在其他方面却有一定的优势，这些患者低血糖的平均发生率和HbA1c水平均较低，体重和腰围方面的不良反应也较少，通常所采用的胰岛素增敏剂为罗格列酮和二甲双胍。