Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes (BARI2D)
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| ClinicalTrials.gov Identifier: NCT00006305 |
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Recruitment Status :
Completed
First Posted : September 29, 2000
Results First Posted : May 12, 2011
Last Update Posted : February 8, 2016
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The BARI 2D trial is a multicenter study that uses a 2x2 factorial design, with 2400 patients being assigned at random to initial elective revascularization with aggressive medical therapy or aggressive medical therapy alone with equal probability, and simultaneously being assigned at random to an insulin providing or insulin sensitizing strategy of glycemic control (with a target value for HbA1c of less than 7.0% for all patients).
SPECIFIC AIMS
A. Primary Aim
The primary aim of the BARI 2D trial is to test the following two hypotheses of treatment efficacy in 2400 patients with Type 2 diabetes mellitus and documented stable CAD, in the setting of uniform glycemic control and intensive management of all other risk factors including dyslipidemia, hypertension, smoking, and obesity:
- Coronary Revascularization Hypothesis: a strategy of initial elective revascularization of choice (surgical or catheter-based) combined with aggressive medical therapy results in lower 5-year mortality compared to a strategy of aggressive medical therapy alone;
- Method of Glycemic Control Hypothesis: with a target HbA1c level of less than 7.0%, a strategy of hyperglycemia management directed at insulin sensitization results in lower 5-year mortality compared to a strategy of insulin provision.
B. Secondary Aims
The secondary aims of the BARI 2D trial include: a) comparing the death, myocardial infarction or stroke combined endpoint event rate between the revascularization versus medical therapy groups and between the insulin sensitization versus insulin provision groups; b) comparing rates of myocardial infarction, other ischemic events, angina and quality of life associated with each revascularization and hyperglycemia management strategy; c) evaluating the relative economic costs associated with the trial treatment strategies, d) exploring the effect of glycemic control strategy on the progression and mechanism of vasculopathy including changes in PAI-1 gene expression.
| Condition or disease | Intervention/treatment | Phase |
|---|---|---|
| Coronary Disease Cardiovascular Diseases Heart Diseases Insulin Resistance Diabetes Mellitus Diabetes Mellitus, Non-Insulin-Dependent | Procedure: Angioplasty, Transluminal, Percutaneous Coronary, other catheter-based interventions Procedure: Coronary Artery Bypass Drug: Biguanides, thiazolidinediones Drug: Insulin, sulfonylurea Drug: ACE Inhibitors, Angiotensin Receptor Blockers, Beta Blockers, Calcium Channel Blockers | Phase 3 |
BACKGROUND:
Type 2 diabetes mellitus, which is becoming more prevalent in our society as the population ages, is one of the strongest risk factors for coronary artery disease (CAD) and consequent mortality. In addition to generating an enormous toll in human suffering, diabetes places an economic burden approaching 100 billion dollars annually on the U.S. health care system. Despite the well known dismal prognosis of diabetes complicated by angiographically documented CAD, the optimal treatment paradigm for this large group of patients has not been studied. Coronary revascularization, while increasingly used, has not been directly shown to be of additional benefit to simultaneous intensive medical management of CAD along with management of hyperglycemia, hypertension, dyslipidemia, and other risk factors. Moreover, while intensive efforts to lower HbA1c have been demonstrated to favorably affect the clinical course of Type 2 diabetes mellitus in terms of microvascular complications, the optimal hyperglycemia management strategy with regard to macrovascular outcome is not known.
These critical treatment dilemmas have motivated the development of BARI 2D, a multicenter randomized trial designed to determine in patients with Type 2 diabetes and stable CAD: 1) the efficacy of initial elective coronary revascularization combined with aggressive medical therapy, compared to an initial strategy of aggressive medical therapy alone; and 2) the efficacy of a strategy of providing more insulin (endogenous or exogenous), versus a strategy of increasing sensitivity to insulin (reducing insulin resistance), in the management of hyperglycemia, with a target HbA1c level of less than 7.0% for each strategy.
DESIGN NARRATIVE:
The BARI 2D trial is a multicenter study that uses a 2x2 factorial design, with 2400 patients being assigned at random to initial elective revascularization with aggressive medical therapy or aggressive medical therapy alone with equal probability, and simultaneously being assigned at random to an insulin providing or insulin sensitizing strategy of glycemic control (with a target value for HbA1c of less than 7.0% for all patients). Following confirmation of patient eligibility and provision of written consent, patients were randomized as shown below:
Number of Patients Per Treatment Assignment (N=2400 patients in total)
Stable Ischemic Heart Disease Treatment Strategy and Glycemic Control Strategy:
Revascularization and Insulin Providing (IP) N=600; Revascularization and Insulin Sensitizing (IS) N=600; Medical and Insulin Providing (IP) N=600; Medical and and Insulin Sensitizing (IS) N=600.
| Study Type : | Interventional (Clinical Trial) |
| Actual Enrollment : | 2368 participants |
| Allocation: | Randomized |
| Intervention Model: | Factorial Assignment |
| Masking: | None (Open Label) |
| Primary Purpose: | Treatment |
| Official Title: | Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes |
| Study Start Date : | September 2000 |
| Actual Primary Completion Date : | November 2008 |
| Actual Study Completion Date : | March 2009 |
| Arm | Intervention/treatment |
|---|---|
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Active Comparator: Revascularization and Insulin Providing (IP)
Prompt revascularization with intensive medical therapy and insulin providing glycemic control strategy
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Procedure: Angioplasty, Transluminal, Percutaneous Coronary, other catheter-based interventions
Angioplasty, Transluminal, Percutaneous Coronary, other catheter-based interventions Procedure: Coronary Artery Bypass Coronary Artery Bypass Drug: Insulin, sulfonylurea Insulin, sulfonylurea Drug: ACE Inhibitors, Angiotensin Receptor Blockers, Beta Blockers, Calcium Channel Blockers ACE Inhibitors, Angiotensin Receptor Blockers, Beta Blockers, Calcium Channel Blockers |
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Active Comparator: Revascularization and Insulin Sensitizing (IS)
Prompt revascularization with intensive medical therapy and insulin sensitizing glycemic control strategy
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Procedure: Angioplasty, Transluminal, Percutaneous Coronary, other catheter-based interventions
Angioplasty, Transluminal, Percutaneous Coronary, other catheter-based interventions Procedure: Coronary Artery Bypass Coronary Artery Bypass Drug: Biguanides, thiazolidinediones Biguanides, thiazolidinediones Drug: ACE Inhibitors, Angiotensin Receptor Blockers, Beta Blockers, Calcium Channel Blockers ACE Inhibitors, Angiotensin Receptor Blockers, Beta Blockers, Calcium Channel Blockers |
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Active Comparator: Medical Therapy and Insulin Providing (IP)
Intensive medical therapy with delayed revascularization if clinically indicated and insulin providing glycemic control strategy
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Drug: Insulin, sulfonylurea
Insulin, sulfonylurea Drug: ACE Inhibitors, Angiotensin Receptor Blockers, Beta Blockers, Calcium Channel Blockers ACE Inhibitors, Angiotensin Receptor Blockers, Beta Blockers, Calcium Channel Blockers |
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Active Comparator: Medical Therapy and Insulin Sensitizing (IS)
Intensive medical therapy with delayed revascularization if clinically indicated and insulin sensitizing glycemic control strategy
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Drug: Biguanides, thiazolidinediones
Biguanides, thiazolidinediones Drug: ACE Inhibitors, Angiotensin Receptor Blockers, Beta Blockers, Calcium Channel Blockers ACE Inhibitors, Angiotensin Receptor Blockers, Beta Blockers, Calcium Channel Blockers |
- Number of Participants With All-Cause Mortality [ Time Frame: five years ]
- Number of Participants With Death, Myocardial Infarction, or Stroke [ Time Frame: five years ]
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| Ages Eligible for Study: | 25 Years and older (Adult, Older Adult) |
| Sexes Eligible for Study: | All |
| Accepts Healthy Volunteers: | No |
Inclusion Criteria:
- Diagnosis of Type 2 diabetes mellitus
- Coronary arteriogram showing one or more vessels amenable to revascularization (greater than or equal to 50% stenosis)
- Objective documentation of ischemia OR subjectively documented typical angina with greater than or equal to 70% stenosis in at least one artery
- Suitability for coronary revascularization by at least one of the available methods (does not require the ability to achieve complete revascularization)
- Ability to perform all tasks related to glycemic control and risk factor management
Exclusion Criteria:
- Definite need for invasive intervention as determined by the attending cardiologist
- Prior bypass surgery (CABG) or prior catheter-based intervention within the 12 months before study entry
- Planned intervention for disease in bypass graft(s) if the patient is randomly assigned to a strategy of initial revascularization
- Class III or IV CHF
- Creatinine greater than 2.0 mg/dL
- HbA1c greater than 13%
- Need for major vascular surgery concomitant with revascularization (e.g., carotid endarterectomy)
- Left main stenosis greater than or equal to 50%
- Non-cardiac illness expected to limit survival
- Hepatic disease (ALT greater than 2 times the ULN)
- Fasting triglycerides greater than 1000 mg/dL in the presence of moderate glycemic control (HbA1c less than 9.0%)
- Current alcohol abuse
- Chronic steroid use judged to interfere with the control of diabetes, exceeding 10 mg of Prednisone per day or the equivalent
- Pregnancy, known, suspected, or planned in 5 years after study entry
- Geographically inaccessible or unable to return for follow-up
- Enrolled in a competing randomized trial or clinical study
- Unable to understand or cooperate with protocol requirements
Patients with Type 2 diabetes mellitus and CAD documented by coronary arteriography will be eligible for the trial if revascularization is not required for prompt control of severe or unstable angina. Diabetic patients who are being treated with insulin or oral hypoglycemic drugs will be eligible as well as diabetic patients treated with diet and exercise alone provided that a diagnosis of diabetes can be confirmed by record review or that a fasting plasma glucose (FPG) greater than 125/mg/dL (7.0 mmol/L) can be obtained. The determination of suitability for BARI 2D will be made by a physician-investigator at each participating institution on clinical grounds at the time of coronary angiography.
Significant CAD will be defined as at least one stenosis greater than 50%. Angina and ischemia will be assessed by use of patient self-report, physician examination, and appropriate diagnostic measures including exercise myocardial perfusion imaging, exercise echocardiography, exercise electrocardiography, and IV dipyridamole or adenosine myocardial perfusion imaging or invasively by doppler or pressure wire. Objective documentation of myocardial ischemia includes any of the following:
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Exercise or pharmacologically-induced:
- Greater than or equal to 1 mm of horizontal or downsloping ST depression or elevation for greater than or equal to 60-80 milliseconds after the end of the QRS complex
- Myocardial perfusion defect
- Myocardial wall motion abnormality
- Stabilized, prior acute coronary syndrome with CK-MB or troponin elevation or with new, greater than or equal to 0.5 mm ST depression or elevation, or T wave inversion of greater than or equal to 3 mm in 2 contiguous ECG leads
- Doppler or pressure wire showing coronary flow reserve (CFR) less than 2.0 or fractional flow reserve (FFR) less than 0.75
Among patients without documented ischemia, only patients with stenosis greater than or equal to 70% presenting with classic anginal symptoms will be eligible for randomization.
To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT00006305
| Principal Investigator: | Bernard Chaitman, MD | St. Louis University | |
| Study Chair: | Robert L Frye, MD | Mayo Clinic | |
| Principal Investigator: | Mark Hlatky | Stanford University | |
| Principal Investigator: | Burton Sobel | University of Vermont & State Agricultural College | |
| Principal Investigator: | Sheryl F. Kelsey, PhD | University of Pittsburgh |
Publications:
Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
| Responsible Party: | Maria Mori Brooks, Associate Professor of Epidemiology, University of Pittsburgh |
| ClinicalTrials.gov Identifier: | NCT00006305 |
| Other Study ID Numbers: |
133 U01HL061744 ( U.S. NIH Grant/Contract ) U01HL061746 ( U.S. NIH Grant/Contract ) U01HL061748 ( U.S. NIH Grant/Contract ) U01HL063804 ( U.S. NIH Grant/Contract ) |
| First Posted: | September 29, 2000 Key Record Dates |
| Results First Posted: | May 12, 2011 |
| Last Update Posted: | February 8, 2016 |
| Last Verified: | January 2016 |
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Cardiovascular Diseases Heart Diseases Coronary Disease Diabetes Mellitus Insulin Resistance Diabetes Mellitus, Type 2 Glucose Metabolism Disorders Metabolic Diseases Endocrine System Diseases Hyperinsulinism Myocardial Ischemia Vascular Diseases Biguanides 2,4-thiazolidinedione Calcium Channel Blockers |
Calcium Adrenergic beta-Antagonists Angiotensin-Converting Enzyme Inhibitors Angiotensin Receptor Antagonists Hypoglycemic Agents Physiological Effects of Drugs Calcium-Regulating Hormones and Agents Adrenergic Antagonists Adrenergic Agents Neurotransmitter Agents Molecular Mechanisms of Pharmacological Action Protease Inhibitors Enzyme Inhibitors Membrane Transport Modulators |