Thrombotic/Thrombolytic Balance as a Cardiac Treatment Determinant in Patients With Diabetes Mellitus and Coronary Artery Disease

BACKGROUND: This study aimed to assess whether the plasminogen activator inhibitor‐1/tissue plasminogen activator (PAI‐1/tPA) ratio as a prothrombotic state is useful for optimizing cardiac treatment strategy. METHODS AND RESULTS: Using BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial data, we used a Cox proportional hazard model to calculate hazard ratios with 95% CIs for cardiac events in patients receiving early revascularization (percutaneous coronary intervention or coronary artery bypass grafting) or medical therapy, separately in patients with low (n=1276) and high (n=894) PAI‐1/tPA ratios. The primary outcome was major cardiac events, which was a composite end point including cardiac death and nonfatal myocardial infarction. The mean±SD follow‐up period was 4.1±1.7 years. The risk of major cardiac events in patients with high PAI‐1/tPA ratio was significantly higher when receiving percutaneous coronary intervention (hazard ratio, 1.84; 95% CI, 1.16–2.93; P=0.01) than when receiving medical therapy, whereas that in patients with low PAI‐1/tPA ratio did not differ significantly between the groups (hazard ratio, 0.95; 95% CI, 0.66–1.36; P=0.77); the interaction between the cardiac treatment strategy and PAI‐1/tPA ratio was significant (P=0.02). However, regardless of the PAI‐1/tPA ratio, major cardiac event risk seemed to be lower in patients receiving coronary artery bypass grafting than in those receiving medical therapy. CONCLUSIONS: In patients with type 2 diabetes mellitus and coronary artery disease, this study demonstrated that those with high PAI‐1/tPA ratio were at higher risks of major cardiac events when treated with percutaneous coronary intervention than when treated with intensive medical therapy.