RESUMEN
Myocardial revascularization in coronary artery disease via percutaneous coronary intervention or coronary artery bypass graft (CABG) surgery effectively relieves symptoms, significantly improves prognosis and quality of life when combined with guideline-directed medical therapy. Hybrid coronary revascularization is a promising alternative to percutaneous coronary intervention or CABG in selected patients and is defined as a planned and/or intended combination of consecutive CABG surgery using at least 1 internal mammary artery to the left anterior descending (LAD), and catheter-based coronary intervention to the non-LAD vessels for the treatment of multivessel disease. The main indications for hybrid coronary revascularization are (i) to achieve complete revascularization in patients who cannot undergo conventional CABG, (ii) to treat patients with acute coronary syndromes and multivessel disease with a non-LAD vessel as the culprit lesion that needs revascularization and (iii) in highly select patients with multivessel disease with complex LAD lesions and simple percutaneous coronary intervention targets for all other vessels. Hybrid coronary revascularization patients receive a left internal mammary artery graft to the LAD artery through a minimal incision along with percutaneous coronary intervention to the remaining diseased coronary vessels using latest generation drug-eluting stents. A collaborative environment with a dedicated heart team is the optimal platform to perform such interventions, which aim to improve the quality and outcome of myocardial revascularization. This position paper analyses the rationale of hybrid coronary revascularization and the currently available evidence on the various techniques and delves into the sequence of the interventions and pharmacological management during and after the procedure.
Asunto(s)
Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/métodos , Enfermedad de la Arteria Coronaria/cirugía , Puente de Arteria Coronaria/métodos , Revascularización Miocárdica/métodos , Revascularización Miocárdica/normas , Europa (Continente)RESUMEN
This cross-sectional study assesses the generalizability of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) guideline by examining the representation of older adults in studies cited in the guideline.
Asunto(s)
Enfermedad de la Arteria Coronaria , Revascularización Miocárdica , Guías de Práctica Clínica como Asunto , Humanos , Anciano , Masculino , Femenino , Estados Unidos , Enfermedad de la Arteria Coronaria/cirugía , Revascularización Miocárdica/normas , Revascularización Miocárdica/estadística & datos numéricos , Revascularización Miocárdica/métodos , American Heart Association , Persona de Mediana Edad , Anciano de 80 o más AñosRESUMEN
PURPOSE OF REVIEW: This article explores recent developments in left main revascularization, with a focus on appraising the latest American and European guidelines. RECENT FINDINGS: Recent pooled data analysis from four major randomized controlled trials (RCTs) for left main coronary artery stenosis indicate an advantage for CABG over PCI in regard to freedom from major adverse cardiovascular events, despite no significant difference in mortality observed at 5âyears. Additional data support the use of CABG for patients with left ventricular dysfunction, complex left main lesions, diffuse coronary disease, and diabetes. SUMMARY: The data underpinning the guidelines on each revascularization modality (PCI versus CABG) must consider factors such as lesion complexity, diabetes, and left ventricular dysfunction. Additionally, the findings of the four major RCTs upon which the guidelines are based must be ascertained in light of the latest advancements in these revascularization techniques.
Asunto(s)
Puente de Arteria Coronaria , Intervención Coronaria Percutánea , Guías de Práctica Clínica como Asunto , Humanos , Puente de Arteria Coronaria/métodos , Intervención Coronaria Percutánea/métodos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/terapia , Revascularización Miocárdica/métodos , Revascularización Miocárdica/normas , Ensayos Clínicos Controlados Aleatorios como Asunto , Estenosis Coronaria/cirugíaAsunto(s)
Revascularización Miocárdica , Humanos , Revascularización Miocárdica/efectos adversos , Revascularización Miocárdica/normas , Resultado del Tratamiento , Intervención Coronaria Percutánea/efectos adversos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Enfermedad de la Arteria Coronaria/cirugíaRESUMEN
BACKGROUND: It remains uncertain whether intravascular ultrasound (IVUS) use and final kissing balloon (FKB) dilatation would be standard care of percutaneous coronary intervention (PCI) with a simple 1-stent technique in unprotected left main coronary artery (LMCA) stenosis. This study sought to investigate the impact of IVUS use and FKB dilatation on long-term major adverse cardiac events (MACEs) in PCI with a simple 1-stent technique for unprotected LMCA stenosis. METHODS: Between June 2006 and December 2012, 255 patients who underwent PCI with 1 drug-eluting stent for LMCA stenosis were analyzed. Mean follow-up duration was 1663 ± 946 days. Long-term MACEs were defined as death, nonfatal myocardial infarction (MI) and repeat revascularizations. RESULTS: During the follow-up, 72 (28.2%) MACEs occurred including 38 (14.9%) deaths, 21 (8.2%) nonfatal MIs and 13 (5.1%) revascularizations. The IVUS examination and FKB dilatation were done in 158 (62.0%) and 119 (46.7%), respectively. IVUS use (20.3 versus 41.2%; log-rank P < 0.001), not FKB dilatation (30.3 versus 26.5%; log-rank P = 0.614), significantly reduced MACEs. In multivariate analysis, IVUS use was a negative predictor of MACEs [hazards ratio 0.51; 95% confidence interval (CI) 0.29-0.88; P = 0.017], whereas FKB dilatation (hazard ratio 1.68; 95% CI, 1.01-2.80; P = 0.047) was a positive predictor of MACEs. In bifurcation LMCA stenosis, IVUS use (18.7 versus 48.0%; log-rank P < 0.001) significantly reduced MACEs. In nonbifurcation LMCA stenosis, FKB dilatation showed a trend of increased MACEs (P = 0.076). CONCLUSION: IVUS examination is helpful in reducing clinical events in PCI for LMCA bifurcation lesions, whereas mandatory FKB dilatation after the 1-stent technique might be harmful in nonbifurcation LMCA stenosis.
Asunto(s)
Angioplastia Coronaria con Balón/normas , Infarto del Miocardio/mortalidad , Revascularización Miocárdica/normas , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Ultrasonografía Intervencional/normas , Anciano , Angioplastia Coronaria con Balón/métodos , Angioplastia Coronaria con Balón/estadística & datos numéricos , Angiografía Coronaria/métodos , Stents Liberadores de Fármacos/normas , Stents Liberadores de Fármacos/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Infarto del Miocardio/terapia , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud/métodos , Modelos de Riesgos Proporcionales , Factores de Riesgo , Resultado del Tratamiento , Ultrasonografía Intervencional/métodos , Ultrasonografía Intervencional/estadística & datos numéricosRESUMEN
BACKGROUND: Prior studies have reported an association between elevated white blood cell count (WBCc) and worse clinical outcomes after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). We assessed the prognostic impact of WBCc in patients undergoing revascularization for left main coronary artery disease (LMCAD). METHODS: In Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL), 1905 patients with LMCAD and low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus CABG. The 1895 patients with baseline WBCc available were grouped in tertiles of WBCc (mean 5.6 ± 0.8, 7.5 ± 0.5, and 10.1 ± 1.6 × 109/L). RESULTS: Five-year rates of the primary endpoint (death, myocardial infarction or stroke) were similar across increasing WBCc tertiles (21.2, 18.9, and 21.6%; P = 0.46). Individual components of the primary endpoint, Bleeding Academic Research Consortium (BARC) 3-5 bleeding, stent thrombosis or graft occlusion and ischemia-driven revascularization were all similar across WBCc tertiles. By multivariable analysis, WBCc as a continuous variable was not an independent predictor of adverse events (hazard radio per 1 × 109/L: 1.02; 95% CI, 0.97-1.08; P = 0.43). Results were consistent in the PCI and CABG arms individually. CONCLUSION: There was no association between baseline WBCc and 30-day or 5-year clinical outcomes after PCI or CABG. The absence of a clear incremental increase in events with increasing WBCc in the current analysis indicates that WBCc should not routinely be used as a prognostic marker or to guide revascularization decisions in patients with LMCAD.
Asunto(s)
Vasos Coronarios/fisiopatología , Recuento de Leucocitos/estadística & datos numéricos , Revascularización Miocárdica/normas , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Anciano , Femenino , Humanos , Recuento de Leucocitos/métodos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud/métodos , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/normas , Intervención Coronaria Percutánea/estadística & datos numéricos , Factores de Riesgo , Resultado del TratamientoRESUMEN
AIM: The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.
Asunto(s)
Cardiología/normas , Puente de Arteria Coronaria/normas , Revascularización Miocárdica/normas , Intervención Coronaria Percutánea/normas , Procedimientos Quirúrgicos Vasculares/normas , American Heart Association/organización & administración , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/terapia , Vasos Coronarios/cirugía , Humanos , Estados Unidos , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
AIM: The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
Asunto(s)
Cardiología/normas , Enfermedad de la Arteria Coronaria/terapia , Revascularización Miocárdica/normas , American Heart Association , Humanos , Revascularización Miocárdica/métodos , Estados UnidosRESUMEN
AIM: The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.
Asunto(s)
Enfermedad de la Arteria Coronaria/terapia , Revascularización Miocárdica/normas , Algoritmos , American Heart Association , Toma de Decisiones Conjunta , Diabetes Mellitus , Terapia Antiplaquetaria Doble , Humanos , Revascularización Miocárdica/métodos , Grupo de Atención al Paciente , Medición de Riesgo , Estados UnidosRESUMEN
The ideal management of spontaneous coronary artery dissection (SCAD) has yet to be clearly defined. We conducted a comprehensive search of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception from 1966 through September 2020 for all original studies (randomized controlled trials and observational studies) that evaluated patients with SCAD. Study groups were defined by allocation to medical therapy (medical therapy) versus invasive therapy (invasive therapy) (ie, percutaneous coronary intervention or coronary artery bypass grafting). The risk of death (risk ratio [RR] = 0.753; 95% confidence interval [CI]: 0.21-2.73; I2 = 21.1%; P = 0.61), recurrence of SCAD (RR = 1.09; 95% CI: 0.61-1.93; I2 = 0.0%; P = 0.74), and repeat revascularization (RR = 0.64; 95% CI: 0.21-1.94; I2 = 57.6%; P = 0.38) were not statistically different between medical therapy and invasive therapy for a follow-up ranging from 4 months to 3 years. In conclusion, in this meta-analysis of observational studies, the long-term risk of death, recurrent SCAD, and repeat revascularization did not significantly differ among patients with SCAD treated with medical therapy compared with those treated with invasive therapy. These findings support the current expert consensus that patients should be treated with medical therapy when clinically stable and no high-risk features are present. Further large-scale studies including randomized controlled trials are needed to confirm these findings.
Asunto(s)
Anomalías de los Vasos Coronarios/cirugía , Revascularización Miocárdica/normas , Tiempo , Enfermedades Vasculares/congénito , Adulto , Anomalías de los Vasos Coronarios/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/métodos , Factores de Riesgo , Resultado del Tratamiento , Enfermedades Vasculares/mortalidad , Enfermedades Vasculares/cirugíaRESUMEN
Internal mammary artery, by far, is the gold standard and first conduit for surgical revascularization especially when it comes to bypassing a lesion in the left anterior descending coronary artery. Several factors behind using this artery have been established, including but not limited to, the anatomical location, the course and flow, the elastic nature of the artery as well as the physiological characteristics that make this conduit to yield excellent long-term patency rates. This review aims to thoroughly examine current literature and establish the facts behind using this conduit in our daily surgical revascularization practice.
Asunto(s)
Enfermedad de la Arteria Coronaria/cirugía , Arterias Mamarias , Revascularización Miocárdica/métodos , Humanos , Arterias Mamarias/anatomía & histología , Arterias Mamarias/fisiología , Arterias Mamarias/cirugía , Revascularización Miocárdica/normas , Evaluación de Resultado en la Atención de Salud , Tiempo , Grado de Desobstrucción VascularRESUMEN
Cardiogenic shock (CS) complicating acute myocardial infarction (MI) is associated with high mortality. In the absence of data to support coronary revascularization beyond the infarct artery and selection of circulatory support devices or medications, clinical practice may vary substantially. METHODS: We distributed a survey to interventional cardiologists and cardiothoracic surgeons through relevant professional societies to determine contemporary coronary revascularization and circulatory support strategies for MI with CS and multi-vessel coronary artery disease (CAD). RESULTS: A total of 143 participants completed the survey between 1/2019 and 8/2019. Overall, 55.2% of participants reported that the standard approach to coronary revascularization was single vessel PCI of the infarct related artery (IRA) with staged PCI of non-culprit lesions. Single vessel PCI of the IRA only (28.0%), emergency multi-vessel PCI (11.9%), and coronary artery bypass grafting (CABG) (4.9%) were standard approaches at some centers. A plurality of survey respondents (46.9%) believed initial PCI with staged CABG for multi-vessel CAD would be associated with the most favorable outcomes. A minority of respondents believed PCI-only strategies (23.1%) and CABG alone (6.3%) provided optimal care, and 23.1% were unsure of the best strategy. After PCI for CS, Impella (76.9%), intra-aortic balloon pump (IABP) (12.8%), and extra-corporeal membrane oxygenation (ECMO) (7.7%) were preferred. After CABG, IABP (34.3%), Impella (32.2%), and ECMO (28%) were preferred. CONCLUSIONS: This survey indicates substantial heterogeneity in clinical care in CS. There is evidence of provider uncertainty and clinical equipoise regarding the optimal management of patients with MI, multi-vessel CAD, and CS. SHORT ABSTRACT: We sought to determine contemporary practice patterns of coronary revascularization and circulatory support in patients with MI, multi-vessel coronary artery disease (CAD), and cardiogenic shock. A survey was distributed to interventional cardiologists and cardiothoracic surgeons through relevant professional societies. Survey respondents identified substantial heterogeneity in clinical care and evidence of provider uncertainty and clinical equipoise regarding the optimal management of patients with MI, multi-vessel CAD, and CS.
Asunto(s)
Puente de Arteria Coronaria/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/terapia , Infarto del Miocardio/terapia , Revascularización Miocárdica/métodos , Intervención Coronaria Percutánea/estadística & datos numéricos , Pautas de la Práctica en Medicina , Choque Cardiogénico/terapia , Cardiotónicos/uso terapéutico , Catecolaminas/uso terapéutico , Terapia Combinada , Enfermedad de la Arteria Coronaria/complicaciones , Encuestas de Atención de la Salud , Humanos , Internacionalidad , Infarto del Miocardio/complicaciones , Revascularización Miocárdica/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos , Choque Cardiogénico/etiologíaRESUMEN
AIMS: Patients with de novo chest pain are usually investigated non-invasively. The new UK-National Institute for Health and Care Excellence (NICE) guidelines recommend CT coronary angiography (CTCA) for all patients, while European Society of Cardiology (ESC) recommends functional tests. We sought to compare the clinical utility and perform a cost analysis of these recommendations in two UK centres with different primary investigative strategies. METHODSRESULTS: We compared two groups of patients, group A (n=667) and group B (n=654), with new onset chest pain in two neighbouring National Health Service hospitals, each primarily following either ESC (group A) or NICE (group B) guidance. We assessed the clinical utility of each strategy, including progression to invasive coronary angiography (ICA) and revascularisation. We present a retrospective cost analysis in the context of UK tariff for stress echo (£176), CTCA (£220) and ICA (£1001). Finally, we sought to identify predictors of revascularisation in the whole population.Baseline characteristics in both groups were similar. The progression to ICA was comparable (9.9% vs 12.0%, p=0.377), with similar requirement for revascularisation (4.0% vs 5.0%.; p=0.532). The average cost of investigations per investigated patient was lower in group A (£279.66 vs £325.77), saving £46.11 per patient. The ESC recommended risk score (RS) was found to be the only predictor of revascularisation (OR 1.05, 95% CI 1.04 to 1.06; p<0.001). CONCLUSION: Both NICE and ESC-proposed strategies led to similar rates of ICA and need for revascularisation in discrete, but similar groups of patients. The SE-first approach had a lower overall cost by £46.11 per patient, and the ESC RS was the only variable correlated to revascularisation.
Asunto(s)
Angina de Pecho/diagnóstico por imagen , Reglas de Decisión Clínica , Angiografía por Tomografía Computarizada/normas , Angiografía Coronaria/normas , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Pruebas de Función Cardíaca/normas , Guías de Práctica Clínica como Asunto/normas , Anciano , Angina de Pecho/economía , Angina de Pecho/fisiopatología , Angina de Pecho/terapia , Enfermedad de la Arteria Coronaria/economía , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/terapia , Vasos Coronarios/fisiopatología , Ahorro de Costo , Análisis Costo-Beneficio , Femenino , Costos de la Atención en Salud , Factores de Riesgo de Enfermedad Cardiaca , Humanos , Londres , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/economía , Revascularización Miocárdica/normas , Valor Predictivo de las Pruebas , Pronóstico , Estudios Retrospectivos , Medición de RiesgoRESUMEN
Different pharmacologic agents have been tested in the effort to prevent contrast-induced acute kidney injury (AKI) in the last two decades. To date, however, no individual drug has received unanimous approval for this aim. Since 2014 statins have been included as preventive treatment in the European guidelines for revascularization procedures in cardiac patients. The present update presents the latest findings in this field focusing on the changing paradigms in the definition and consequently the approach to nephroprotection that considers clinical prognosis as the major issue. We note the current shift from attention to contrast-induced AKI to contrast-associated AKI.
Asunto(s)
Lesión Renal Aguda/inducido químicamente , Lesión Renal Aguda/prevención & control , Medios de Contraste/efectos adversos , Solución Salina Hipertónica/farmacología , Lesión Renal Aguda/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Angiografía/efectos adversos , Europa (Continente)/epidemiología , Femenino , Fluidoterapia/métodos , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/efectos adversos , Revascularización Miocárdica/normas , Nicorandil/uso terapéutico , Guías de Práctica Clínica como Asunto , Factores de Riesgo , Trimetazidina/uso terapéutico , Vasodilatadores/uso terapéuticoRESUMEN
Although cardiologists have long treated patients with coronary artery disease (CAD) and concomitant type 2 diabetes mellitus (T2DM), T2DM has traditionally been considered just a comorbidity that affected the development and progression of the disease. Over the past decade, a number of factors have shifted that have forced the cardiology community to reconsider the role of T2DM in CAD. First, in addition to being associated with increased cardiovascular risk, T2DM has the potential to affect a number of treatment choices for CAD. In this document, we discuss the role that T2DM has in the selection of testing for CAD, in medical management (both secondary prevention strategies and treatment of stable angina), and in the selection of revascularization strategy. Second, although glycemic control has been recommended as a part of comprehensive risk factor management in patients with CAD, there is mounting evidence that the mechanism by which glucose is managed can have a substantial impact on cardiovascular outcomes. In this document, we discuss the role of glycemic management (both in intensity of control and choice of medications) in cardiovascular outcomes. It is becoming clear that the cardiologist needs both to consider T2DM in cardiovascular treatment decisions and potentially to help guide the selection of glucose-lowering medications. Our statement provides a comprehensive summary of effective, patient-centered management of CAD in patients with T2DM, with emphasis on the emerging evidence. Given the increasing prevalence of T2DM and the accumulating evidence of the need to consider T2DM in treatment decisions, this knowledge will become ever more important to optimize our patients' cardiovascular outcomes.