Effectiveness of percutaneous coronary intervention with drug-eluting stents compared with bypass surgery in diabetics with multivessel coronary disease: comprehensive systematic review and meta-analysis of randomized clinical data.
BACKGROUND
Controversy persists regarding the optimal revascularization strategy for diabetic patients with multivessel coronary artery disease (MVD). Coronary artery bypass grafting (CABG) has been compared with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in recent randomized controlled trials (RCTs).


RESULTS
RCTs comparing PCI with DES versus CABG in diabetic patients with MVD who met inclusion criteria were analyzed (protocol registration No. CRD42013003693). Primary end point (major adverse cardiac events) was a composite of death, myocardial infarction, and stroke at a mean follow-up of 4 years. Analyses were performed for each outcome by using risk ratio (RR) by fixed- and random-effects models. Four RCTS with 3052 patients met inclusion criteria (1539 PCI versus 1513 CABG). Incidence of major adverse cardiac events was 22.5% for PCI and 16.8% for CABG (RR 1.34, 95% CI 1.16 to 1.54, P<0.0001). Similar results were obtained for death (14% versus 9.7%, RR 1.51, 95% CI 1.09 to 2.10, P=0.01), and MI (10.3% versus 5.9%, RR 1.44, 95% CI 0.79 to 2.6, P=0.23). Stroke risk was significantly lower with DES (2.3% versus 3.8%, RR 0.59, 95% CI 0.39 to 0.90, P=0.01) and subsequent revascularization was several-fold higher (17.4% versus 8.0%, RR 1.85, 95% CI 1.0 to 3.40, P=0.05).


CONCLUSIONS
These data demonstrate that CABG in diabetic patients with MVD at low to intermediate surgical risk (defined as EUROSCORE <5) is superior to MVD PCI with DES. CABG decreased overall death, nonfatal myocardial infarction, and repeat revascularization at the expense of an increase in stroke risk.
Division of Cardiovascular Diseases, Department of Medicine, University of Arkansas for Medical Sciences.
Abdul
A
Hakeem
Nadish
N
Garg
Sabha
S
Bhatti
Naveen
N
Rajpurohit
Zubair
Z
Ahmed
Barry F
BF
Uretsky
D016009:Chi-Square Distribution; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D003925:Diabetic Angiopathies / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D054855:Drug-Eluting Stents; D006801:Humans; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality / Q000628:therapy; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000628:therapy; D013997:Time Factors; D016896:Treatment Outcome
CABG; PCI; diabetes; multivessel disease