Original Scientific Paper

Evidence-based medication and revascularization:

powerful tools in the management of patients with
diabetes and coronary artery disease: a report from the
Euro Heart Survey on diabetes and the heart
Matteo Anselminoa, Klas Malmbergb, John Öhrvikb, Lars Rydénb and

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on behalf of the Euro Heart Survey Investigators

a
University Department of Cardiology, San Giovanni Battista-Molinette-Hospital, Turin, Italy and
b
Department of Medicine, Karolinska Institutet, Stockholm, Sweden
Received 29 September 2007 Accepted 10 October 2007

Background Patients with diabetes mellitus (DM) and coronary artery disease (CAD) have a poor prognosis.
Underutilization and reduced efficacy of evidence-based medications (EBM) or revascularization are among suggested
explanations. This report compares the impact of EBM and revascularization on mortality and cardiovascular events
(CVE = mortality, myocardial infarction or stroke) in CAD patients with and without DM.
Design Between February 2003 and January 2004 the Euro Heart Survey on Diabetes and the Heart recruited patients with
CAD at 110 centers in 25 European countries. The patients were followed with respect to one-year CVE.
Methods The study population included a total of 3488 patients: 2063 (59%) in the non-DM and 1425 (41%) in the DM
group. EBM was defined as the combined use of renin-angiotensin-aldosterone system inhibitors, b blockers, antiplatelets
and statins while revascularization comprised thrombolysis, percutaneous coronary intervention or coronary artery bypass
grafting.
Results Of the eligible patients, 44% with DM and 43% of those without DM received EBM, while 34 and 40% were
revascularized. In patients with DM both EBM (0.37, 95% confidence interval (CI), 0.20–0.67, P = 0.001) and revascularization
(0.72, 95% CI, 0.39–1.32, P = 0.275) had an independent protective effect as regards one-year mortality and as regards CVE
(0.61, 95% CI, 0.40–0.91, P = 0.015 and 0.61, 95% CI, 0.39–0.95, P = 0.025, respectively) in patients with DM compared with
the impact of these two approaches in those without DM.
Conclusion The systematic use of EBM and revascularization has a highly rewarding, favorable impact on one-year
prognosis of DM patients with CAD. Eur J Cardiovasc Prev Rehabil 15:216–223 c 2008 The European Society of
Cardiology

European Journal of Cardiovascular Prevention and Rehabilitation 2008, 15:216–223

Keywords: cardiovascular endpoints, coronary artery disease, diabetes mellitus, evidence-based medication, mortality, revascularization

Introduction ment of cardiovascular disease, patients with DM have

A vast majority of patients with coronary artery disease
(CAD) have abnormal glucose regulation, and as many as
30% of the patients have overt diabetes mellitus (DM)
[1]. Despite considerable improvement in the manage-
Correspondence to Lars Rydén, MD, Department of Cardiology, Karolinska
University Hospital, 171 76 Stockholm, Sweden
Tel: + 46 8 51772171; fax: + 46 8 344964;
e-mail: lars.ryden@ki.se
These data have not been published elsewhere but they have been accepted as
an abtsract (oral presentation) at the ESC annual congress Vienna, September
2007.
1741-8267
c 2008 The European Society of Cardiology
not benefited to the same extent as those without [2].
Possible explanations are that patients with DM, in
contrast to their non-DM counterparts, are less system-
atically exposed to evidence-based medications (EBM)
or revascularizations [3,4] and/or that these treatment
modalities are less effective in these patients [5].
The STENO 2 study clearly demonstrated the value of a
target-driven, multifactorial intervention, aiming at all
modifiable risk factors in a group of DM patients selected

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 Treatment of diabetes mellitus patients with coronary artery disease Anselmino et al. 217
due to their high risk for microvascular and macrovascular
complications [6]. This observation makes it of interest
to expand the information on the impact of the use of a
combination of all EBM or of revascularization proce-
dures, in routinely managed patients with CAD and DM.
The purpose of the present report from the Euro Heart
Survey on diabetes and heart is to describe the impact of
EBM and revascularization with respect to mortality and
cardiovascular events (CVE) during one-year of follow-up
in a large cohort of patients with CAD and established
DM.
Methods
Between February 2003 and January 2004, the Survey
recruited a total of 4961 patients with CAD at 110
centers in 25 European countries. Complete details of the
survey have been previously reported [1,7]. In brief,
consecutive patients were screened for a diagnosis of
CAD when admitted to hospital wards or visiting
outpatient clinics at the participating centers. All patients
were assessed, investigated and treated at the discretion
of responsible physicians according to the local institu-
tional practice. Clinical characteristics, interventions and
results of laboratory tests were collected by means of a
web-based case record form. The follow-up data were
collected in each center and registered on a web-based
questionnaire. Ninetyfour percent of the recruited
patients (n = 4676) were followed, for at least one year
(median = 374 days, lower and upper quartiles (Q1–Q3),
366–397), with respect to treatment, survival and CVE.
Definitions
Glucometabolic state
The presence of known DM was recognized if this
diagnosis was established before enrolment, reported in
the medical records, declared directly by the patient or
revealed by the use of glucose-lowering drugs. The
diagnosis of normal glucose regulation, impaired glucose
regulation (including both impaired fasting glucose and
impaired glucose tolerance) and newly detected DM
was based on an oral glucose tolerance test (OGTT)
performed during index consultation, or on fasting plasma
glucose (FPG) if an OGTT, although required by the
study protocol, was unavailable [1]. The glucometabolic
classification followed definitions given by the WHO [8].
A total of 736 patients, without known glucometabolic
abnormalities and without a reported FPG or an OGTT,
could not be classified and were therefore excluded from
further analyses. Glucometabolic assessments were avail-
able for 3940 patients of whom 947 (24%) were diagnosed
as normal and 1116 (28%) with impaired glucose
regulation while 452 (11%) had newly detected DM
and 1425 (36%) had previously known DM.
A preliminary analysis was performed for observed CVE
during one year in patients with normal or impaired
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Fig. 1
Enrolled 4961
Lost to follow-up 285
Initial patients cohort 4676
Glucometabolic state unknown 736
Glucometabolic state available 3940
Newly detected diabetes
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452
Study population 3488
947 1116
Normal glucose Impaired glucose
regulation regulation
1425
DM
2063
Non-DM
Description of study population (DM, diabetes mellitus).
glucose regulation and with newly detected or known
DM. Since baseline characteristics and the one-year CVE
pattern were equivalent in patients with normal and
impaired glucose regulation, they were pooled into the
non-DM group. Evidence on the best management of
patients with newly detected DM is hitherto lacking. As
recently reported [7], these patients were at an inter-
mediate risk for one-year CVE compared to patients with
or without DM. Given these presumptions the 452
patients with newly detected DM were excluded from
further analysis in order to avoid contamination of the
two final study groups that consisted of 3488 patients
of whom 2063 (59%) were free from DM and 1425 (41%)
had DM, respectively (Fig. 1).
Therapeutic groups
To avoid considering patients who withdraw treatment
within the year of follow-up, the treatment basis for group
allocation was that which was recorded at the time of
follow-up. Patients who received a poly-pharmacological
treatment including renin-angiotensin-aldosterone sys-
tem inhibitors, b blockers, statins and oral antiplatelet
therapy (aspirin, ticlopidine or clopidogrel, alone or in
combination) were defined as belonging to the EBM
group. Based on the judgment of the attending physi-
cians, as reported in the case record forms, patients with
contraindications to the use of one or more of these drugs
were excluded. Thus, patients not receiving EBM are
 218 European Journal of Cardiovascular Prevention and Rehabilitation 2008, Vol 15 No 2
those who were left untreated despite the absence of any
contraindications. The revascularization group included
patients who, during index hospitalization were subjected
to intravenous thrombolysis, a percutaneous coronary
intervention (PCI) or a coronary artery bypass grafting
(CABG).
Statistical methods
Continuous variables are expressed as medians with lower
and upper quartiles (Q1–Q3) and categorical parameters
as percentages. Continuous variables were compared
between strata by means of Wilcoxon–Mann–Whitney
test, and categorical variables in two-way tables by
means of Fisher’s exact test. Kaplan–Meier curves were
computed for all-cause mortality and composite CVE
(all-cause mortality, myocardial infarction and stroke); the
log-rank test compared differences within groups.
Multiple Cox proportional hazard regression was used to
detect a possible association between EBM or revascular-
ization and one-year events. The models contained the
interaction term between the DM status and treatment
received (EBM or revascularization), in order to test the
dependence of the DM status on the treatment effect,
and was adjusted for all confounders detected from the
clinical patient characteristics (age, gender, current
smoking, hypertension, hyperlipidemia, cerebrovascular
disease, peripheral artery disease, history of heart dis-
ease and interventions for this, diagnosis at discharge;
revascularization interventions for the EBM model, and
medications at follow-up for the revascularization model).
The models were found by combining stepwise forward
and backward analyses to avoid multicollinearity pro-
blems, and the assumption of proportional hazards was
assessed and satisfied by visual inspection of the log–log
survival curves for the categorical variables. The contin-
uous variables were classified and a graphical approach
was applied to verify the linearity assumption.
Results are reported as hazard ratios with associated
95% confidence intervals (CI). A two-sided P value less
than 0.05 was considered as statistically significant. The
unadjusted number needed to treat to avoid a CVE
during the year of follow-up was calculated for EBM or
revascularization both in patients with DM (n = 1425)
and those with normal glucose regulation (n = 947).
All statistical analyses were performed with STATISTICA
v 7.1 (StatSoft, Inc., Tulsa, Oklahama, USA).
Ethical consideration
The National Survey coordinators took the responsibility
for assuring compliance with the ethical requirements in
each country. The patients were enrolled following an oral
and/or written informed consent with respect to the local
rules, and were informed about the follow-up after one year.
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Results
Among the 1425 patients with DM and the 2063 patients
without DM, at least one of the EBM was contraindicated
in 142 (10%) and 161 (8%) of the patients. The use of
EBM in the remaining 3185 patients was similar among
patients with and without DM (44 vs. 43%, respectively,
P = 0.386). Revascularization procedures were less com-
mon (33 vs. 40%, P < 0.001) in the DM group. Data
including pertinent patient characteristics and final
diagnosis are presented in Table 1, which also includes
medications at follow-up and performed interventions.
The information has been stratified by the presence of
DM or not and on treatment received. DM patients
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prescribed EBM were younger (58–74 vs. 69, 61–75, 67%,
P < 0.001), less often smokers (P = 0.049) and were more
frequently hypertensive (P = 0.005). They had under-
gone more PCI interventions (P = 0.002) and were more
commonly discharged with the diagnosis of Q-wave
myocardial infarction (P = 0.001) compared with DM
patients not given EBM. During index hospitalization
patients with DM in the EBM group were more
frequently revascularized with PCI (P < 0.001) and
CABG (P = 0.021). DM patients in the revascularized
group were younger (67, 59–74 vs. 69, 61–75, 67%,
P < 0.001) and more often males (P = 0.019) and they
less frequently presented with a history of previous
cardiovascular disease (P = 0.018). At the baseline, they
less often presented with previous cerebrovascular
(P < 0.001) and peripheral artery disease (P < 0.001),
and they were more often on statin medication at follow-
up (P < 0.001).
FPG levels at enrolment did not significantly differ
comparing DM patients receiving EBM or not while
revascularized DM patients had higher glucose levels
than those not revascularized (8.9 mmol/l, 6.8–12.0 vs.
7.4, 6.4–9.8%, P < 0.001).
All-cause mortality, myocardial infarction, stroke, and
combined CVE by the diagnosis of DM and prescribed
treatment are reported in Table 2. DM patients on EBM
had a significantly lower all-cause mortality (3.5 vs. 7.7%,
P = 0.001) and also fewer combined CVE (11.6 vs. 14.7%,
P = 0.050) compared to those not receiving such treat-
ment. Likewise, revascularized DM patients had sig-
nificantly fewer of the investigated endpoints (all-cause
mortality of 5.7 vs. 8.6%, P = 0.042 and combined CVE of
9.9 vs. 16.9%, P < 0.001) compared to those that were not
revascularized.
Kaplan–Meier curves for all-cause mortality (Figs 2a and
3a) and the combined CVE (Figs 2b and 3b) stratified by
the presence of DM and by the use of EBM and
revascularization show the difference in outcome for
patients prescribed compared to those not given these
treatments. Following adjustment for potential mis-
leading confounders (see Table 1, P-values < 0.05), the
 Treatment of diabetes mellitus patients with coronary artery disease Anselmino et al. 219

Table 1Baseline characteristics, diagnosis at discharge or after the index outpatient visit, medications at follow-up, and interventions
(shown as %) stratified by presence of diabetes and treatment received
Non-DM (n = 2063) DM (n = 1425)

EBM RV EBM RV

Baseline characteristics All Yes 814 No 1088 Yes 816 No 1247 All Yes 569 No 714 Yes 476 No 949

Males 73.2 74.5 72.3 79.8 69.9 63.5 64.3 63.3 67.9 61.5
Age (median, years) 64 64 65 61 66 68 67 69 67 69
Current smokers 13.7 14.7 12.4 12.0 14.8 10.8 10.0 11.6 9.4 11.5
Hypertension 62.4 66.9 59.0 55.4 67.0 78.0 81.7 74.4 78.0 78.0
Hyperlipidaemia 62.1 72.1 56.3 56.5 65.8 65.5 60.2 73.6 58.8 68.8
Cerebrovascular disease 11.6 12.1 11.4 7.4 14.4 16.7 15.8 17.8 12.2 19.0
Peripheral artery disease 12.8 13.5 12.7 7.6 16.1 23.6 23.6 23.7 16.2 27.2
Previous
Coronary artery disease 20.8 20.4 21.7 16.9 23.3 21.3 22.0 20.3 17.7 23.1
Myocardial infarction 42.0 47.2 38.1 31.3 49.2 47.1 49.9 44.8 35.7 52.9

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Congestive heart failure 18.1 21.8 15.2 9.1 24.0 32.8 34.8 31.8 18.9 39.8
PCI 22.6 25.3 20.6 18.3 25.4 20.4 24.1 17.1 17.2 22.0
CABG 14.5 18.0 12.8 8.5 18.4 21.3 24.1 20.0 13.5 25.2
FPG (median, mmol/l) 5.5 5.6 5.4 5.6 5.4 7.8 7.8 7.7 8.9 7.4
Diagnosis at discharge
Q wave MI 33.5 41.6 28.0 37.8 30.6 31.3 36.7 27.0 33.1 30.3
Non Q wave MI 16.4 16.4 17.1 18.3 15.2 16.0 15.2 16.7 18.6 14.7
Unstable angina 17.5 13.3 20.7 19.4 16.2 20.1 20.3 20.7 21.3 19.5
Stable angina 32.6 28.7 34.2 24.5 37.9 32.6 27.8 35.7 27.0 35.4
Medications at follow-up
Beta blockers 79.8 64.7 82.8 77.9 73.5 52.4 76.7 72.0
ACE-inhibitors/ARBs 68.5 44.9 69.3 68.0 78.0 60.5 77.4 78.3
Oral antiplatelets 87.9 84.0 90.8 85.9 86.4 84.2 87.0 86.1
Statins 74.6 55.6 81.3 70.2 72.8 51.0 78.9 69.8
Interventions
Thrombolysis 0.7 10.0 8.9 15.3 1.2 7.9 5.1 11.1
PCI 33.2 37.0 29.5 68.0 27.3 31.6 23.0 66.4
CABG 16.5 18.7 14.5 28.0 17.6 20.2 15.3 33.4

Values in bold represent P-values (Wilcoxon–Mann–Whitney or Fisher exact test) < 0.05 comparing patients receiving (Yes) or not (No) evidence-based medications
(EBM) or undergoing (Yes) or not (No) revascularization (RV). ARBs, angiotensin receptor blockers; CABG, coronary artery bypass grafting; FPG, fasting plasma glucose
at enrolment; MI, myocardial infarction; PCI, percutaneous coronary intervention.

Table 2 Follow-up events (shown as %) stratified by the presence of diabetes and treatment received
Non-DM (n = 2063) DM (n = 1425)

EBM RV EBM RV

Endpoint (%) All Yes 814 No 1088 Yes 816 No 1247 All Yes 569 No 714 Yes 476 No 949

All-cause mortality 2.5 2.2 2.1 2.5 2.5 7.6 3.5 7.7 5.7 8.6
Myocardial infarction 2.5 3.4 2.0 2.5 2.6 5.3 5.8 5.3 2.9 6.5
Stroke 1.4 1.0 1.8 0.5 1.9 3.5 3.5 3.9 2.1 4.2
Combined CVE 6.0 6.3 5.8 5.2 6.6 14.5 11.6 14.7 9.9 16.9

Values in bold show P-values (Fisher exact test) < 0.05 comparing patients receiving (Yes) or not (No) evidence-based medications (EBM) or undergoing (Yes) or not
(No) revascularization (RV). CVE, cardiovascular events.

proportional hazard ratios for the interaction between
DM status and treatment received (Fig. 4) revealed that
the impact of the use of EBM and of revascularization in
patients with DM had an independent protective effect
(e.g. for death hazard ratio of 0.37 and 0.72, respectively),
compared with the effects of these approaches on non-
DM patients.
The number of patients needed to treat with EBM to
avoid one death was 24 in the DM group compared with
1826 in patients with normal glucose regulation, and
the corresponding numbers to avoid one combined CVE,
32 and 141, in the two groups respectively. Regarding
revascularization the number needed to treat to avoid one
death and one combined CVE were 34 vs. 105 and 14 vs.
41 in patients with DM and normal glucose regulation,
respectively.
Discussion
The main finding of this study is that DM patients with
CAD benefit to a greater extent from EBM treatment
and revascularization than their non-DM counterparts.
A substantially lower number of DM patients have to be
treated during one year to save one life or to avoid a
major CVE.
The proportion of patients with abnormal glucose
regulation was 36%. This is somewhat higher than the
proportions reported from previous Euro Heart Surveys

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 220 European Journal of Cardiovascular Prevention and Rehabilitation 2008, Vol 15 No 2

Fig. 2 Fig. 3

(a) 1.00 (a) 1.00

Cumulative proportion surviving

Cumulative proportion surviving

0.99 0.99
0.98 0.98
0.97 0.97
P < 0.001
0.96 0.96
0.95
0.95 P < 0.001 0.94
0.94
0.93
0.93 0.92
0.92 0.91
0 0
0 50 100 150 200 250 300 350 400 0 50 100 150 200 250 300 350 400

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Time (days) Time (days)
Patients at risk Patients at risk
Non-DM, treated 814 808 803 796 Non-DM, treated 816 809 801 797
Non-DM, untreated 1088 1082 1077 1068 Non-DM, untreated 1247 1239 1229 1216
DM, treated 569 562 556 551 DM, treated 476 461 456 452
DM, untreated 714 696 676 661 DM, untreated 949 925 894 870

Cumulative proportion free from CVE

(b)
Cumulative proportion free from CVE

(b) 1.00
1.00
0.98 0.98
0.96
0.96
0.94
0.94
0.92
0.92 0.90
P<0.001
0.90 0.88
P< 0.001
0.88 0.86
0.86 0.84
0.84 0.82
0 0
0 50 100 150 200 250 300 350 400 0 50 100 150 200 250 300 350 400
Time (days) Time (days)
Patients at risk
Patients at risk
Non-DM, treated 816 802 790 779
Non-DM, treated 814 800 790 767
Non-DM, untreated 1247 1225 1203 1173
Non-DM, untreated 1088 1069 1053 1036
DM, treated 476 454 444 437
DM, treated 569 552 531 514
DM, untreated 949 913 858 808
DM, untreated 714 687 655 623

Kaplan–Meier curves on survival (a) and cardiovascular events (b)

Kaplan–Meier curves of survival (a) and cardiovascular events (b) comparing patients with and without diabetes (DM) who were
comparing patients with and without diabetes (DM) prescribed or revascularized or not. Non-DM (K or *) and DM (’ or &) patients
not on evidence-based medications (EBM). Non-DM (K or *) and DM who underwent or did not undergo revascularization.
(’ or &) patients receiving or not receiving EBM.

Prognosis after CAD is more severe in patients with DM

on patients with stable CAD as the EUROASPIRE
(18–23%) [9], acute coronary syndromes survey (21 to
32% depending on the ECG pattern) [10], and in a
population-based registry of patients with myocardial
infarction [4]. An explanation may be that investigators in
the Euro Heart Survey on diabetes and heart were
specifically asked to look for previously diagnosed DM
and instructed to perform an OGTT on patients without
known abnormal glucose metabolism. There are, indeed,
reasons to believe that the present finding is closer to
reality than the previously reported lower proportions.
The important implication is that diabetes is very
common in patients with CAD and therefore in need of
great attention as regards special therapeutic demands.
than among those without DM [2]. One reason may be
that EBM and revascularization are less commonly
applied in patients with DM [3,4]. In the present survey
the proportion of patients that were given full EBM did
not differ between the two groups while patients with
DM, were less commonly revascularized. These findings
are simply descriptive and not adjusted for clinical
confounders since the discussion of a possible under-
treatment of DM patients was outside the aim of this
investigation, and indeed already reported on from the
present population [11].
Another possible explanation, in the focus of this report,
is that treatment modalities with proven efficacy in a

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 Treatment of diabetes mellitus patients with coronary artery disease Anselmino et al. 221
Fig. 4
HR 95% CI P patients with CAD require this procedure and the
0.37 0.20−0.67 0.001
All-cause mortality
0.72 0.39− 1.32 0.275
All-cause mortality or 0.46 0.29−0.74 0.001
myocardial infarction 0.55 0.34− 0.90 0.015
0.61 0.40− 0.91 0.015
Combined CVE
0.61 0.39− 0.95 0.025
0.5 1 1.5
Adjusted hazard ratios for the interaction between diabetic status and
treatment received (evidence-based medications in black and
revascularization in grey). CVE, cardiovascular events.
non-DM population may be less efficient in patients
with DM.
Renin-angiotensin-aldosterone system inhibitors [12–14],
b blockers [15–17], statins [18–21] and antiplatelet
therapy [22] reduce cardiovascular events. Their appro-
priate use has recently been extensively advocated in the
European Society of Cardiology and the European
Association for the Study of Diabetes guidelines on
diabetes, pre-diabetes and cardiovascular diseases [23].
So far most studies have been devoted to the therapeutic
impact of selected drugs, often based on post hoc created
subgroups of DM patients, rather than combinations of
these compounds. This observation is of interest for
expanding the information on the impact of the use of a
combination of all these medications on the prognosis of
patients with DM and CAD. It is well known that the
presence of multiple modifiable risk factors for complica-
tions in DM patients, including hypertension and
dyslipidemia, increases the risk of a poor cardiovascular
outcome. In the present population the simultaneous
treatment of all risk factors by a comprehensive secondary
prevention based on the combination of established
pharmaceutical regimes improved the prognosis of DM
patients by a substantial reduction of cardiovascular
events clearly demonstrable already after one year of
follow up. In the light of the present data, a multi-
factorial intervention approach has to be offered to DM
patients. Future studies should assess if a closer colla-
boration between cardiologists and representatives
from other specialities, in particular diabetologists, are
needed to accomplish this goal and which type of care
is the most effective in implementing this therapeutic
approach.
Regarding revascularization procedures, previous studies
reported on the favorable effect of thrombolytic drugs
[24,25], PCI and stenting [26] and CABG [27] in
patients with DM.
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In the present survey, 33 and 40% of the patients with
and without DM were revascularized. Obviously not all
present focus is on the comparative efficacy in patients
with and without DM, and not on the indications for
revascularization in itself. These were left in the hands of
responsible physicians.
The present results give support to data reported from
the MONICA registry [25] that concluded that the use of
thrombolytic drugs was more powerful in reducing risk
ratios in DM than in non-DM patients (risk ratio 0.57 vs.
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0.65, respectively).
The number needed to treat analyses were performed to
evaluate the clinical usefulness of the investigated
treatments in the two extremes of the glucometabolic
abnormalities: patients with normal glucose regulation
and those with established DM. The finding that the
number of patients with DM to be treated to save one
CVE is lower than that of patients with normal glucose
regulation is based on crude incidence rates. Accordingly,
it may be biased by different baseline characteristics
within patients receiving or not receiving the investigated
treatments. It is probably explained by the higher total
risk for CVE in DM compared with non-DM patients
rather than only an increased efficacy of EBM and
revascularization among the former cohort. Still, it
underlines that a comprehensive management of these
patients should easily translate to a cost-effective
approach. Although reporting on more restricted pharma-
cological approaches than the present demands of full
EBM, similar results were derived in previous studies on
statins [19], aspirin, b blockers and angiotensin-convert-
ing enzyme inhibitors [28,29] showing that clinical
benefit achieved may be greater in patients with DM
compared with those without DM.
Study limitations
The present patients were recruited to be the represen-
tative as possible for a general population of patients with
CAD. Intentionally, the period of recruitment was kept
short and the number of patients asked for from each
center was modest to simplify the process and to help
ensure high quality data and consecutive recruitment.
The strength with surveys of the present kind is that they
recruit patients seen in everyday practice without any
exclusion criteria. Still, since most patients originated
from hospital settings, it should be acknowledged that
they might not be representative for those cared for in
primary care. With this potential limitation, the size and
wide geographical recruitment area make it reasonable to
assume that patterns disclosed by the survey represent a
true picture of the actual situation.
 222 European Journal of Cardiovascular Prevention and Rehabilitation 2008, Vol 15 No 2
A shortcoming of the present study is that EBM or
revascularization procedures could have been mainly
prescribed to low-risk patients. Only a randomized
clinical trial can solve this issue. There is, however, no
reason that this selection bias should be differently
distributed in patients with and without DM. Thus, it
should not affect the comparison of treatment efficacy in
the two groups of patients. In addition, adjustments were
introduced in the proportional hazard regression to limit
this bias. It may be said that the weaker treatment impact
in the non-DM compared with the DM group may relate
to fewer events in the former group with the implication
that the present time of follow-up may be too short to
detect the ‘true’ beneficial effects in the non-DM group.
This, however, does not change the conclusion that a
comprehensive management of DM patients is very
important and highly rewarding from even a fairly short-
term perspective.
Concluding remarks
In conclusion, this large European survey on patients with
CAD and DM clearly shows that this patient category
benefits to a greater extent compared with their non-DM
counterparts from treatment with EBM or revasculariza-
tion. Consequently, a considerably lower number of DM
patients have to be treated to save a life or a major CVE
during the first year of follow-up.
Undertreatment of this high risk-group of patients should
be carefully avoided so as to benefit from the highly
rewarding effects of the available treatments. This should
not focus on isolated components, but be as comprehen-
sive as possible.
Acknowledgements
Funding: this report was supported by unconditional
grants from the Swedish Heart and Lung Foundation,
AFA Insurance and Sanofi-Aventis. None of these
providers of research funds had any role in the analyses,
interpretation of data or in the preparation and approval
of the manuscript.
Conflict of interest: none of the authors have any
financial interests, or relationships and affiliations related
to the relevance to the subject of this manuscript.
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