Translating Scientific Evidence Into Clinical Practice: Closing the Loop

Abstract

See article by Miller et al., pages 1236e1243 of this issue.Clinical practice guidelines recommend coronary artery bypass surgery (CABG) as the optimal revascularization strategy in patients with diabetes and multivessel coronary disease. [1][2][3] Although many trials have studied this issue, the Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) was the first adequately powered trial to compare CABG vs percutaneous coronary intervention (PCI) with drug-eluting stents in patients with diabetes, in addition to optimal medical therapy. 4 A total of 1900 patients were randomized and, after a median follow-up of 3.8 years, CABG, compared with PCI, reduced the composite of allcause mortality, nonfatal myocardial infarction, and stroke (18.7% vs 26.6%; P ¼ 0.005). 4 A long-term follow-up of this trial (median of 7.5 years) showed that PCI was associated with excess mortality, with a hazard ratio of 1.36 (95% confidence interval [CI], 1.07-1.74; P ¼ 0.01). 5 A pooled analysis of patient-level data from 11 clinical trials, including 3266 patients with diabetes and multivessel disease, also corroborated these findings. 6 The results of the FREEDOM trial were first presented at the American Heart Association Congress on November 4, 2012 and simultaneously published online. 4 The FREEDOM results were gradually incorporated into clinical practice guidelines internationally. [1][2][3] The ultimate goal of clinical research is to inform clinical practice, providing better care to our patients. This process usually begins at the bedside, by recognizing a knowledge gap, which will lead to a clinically relevant research question to be pursued in a trial. The cycle is completed when the scientific evidence generated by the trial is incorporated into guidelines and ultimately into clinical practice, benefiting patients. Although