Ancillary Studies in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial: Synergies and Opportunities

The definitive power of randomized controlled trials (RCTs) to characterize the efficacy of putative therapeutic approaches cannot be overestimated. Such trials are expensive, and their implementation requires prolonged and intensive commitments by both investigators and subjects. Accordingly, enhancing their value, in a sense increasing the “scientific return on investment,” is a laudatory objective. Ancillary studies afford a great opportunity to do so. They permit acquisition of new knowledge, elucidation of cause/consequence relation, and delineation of pathogenetic mechanisms at a much lower cost than would be possible if they were performed independently of the parent RCTs. In addition, their utility is enhanced by internal consistency under the rubric of the parent trial and the presumed external validation of the parent trial. Several ancillary studies undertaken in conjunction with the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial provide cogent examples. They seek to delineate causal connections linking the accelerated coronary disease typical of diabetes with phenomena such as genetic predisposition to altered expression of cytokines and fibrinolytic system proteins, inflammation, procoagulation, insulin-induced impairment of fibrinolysis, insulin resistance, and the response to insulin-sensitizing and insulin-providing treatment strategies.