title: Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised controlled trials.
abstract: BACKGROUND
  The choice between coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) for revascularisation in patients with diabetes and multivessel coronary artery disease, who account for 25% of revascularisation procedures, is much debated. We aimed to assess whether all-cause mortality differed between patients with diabetes who had CABG or PCI by doing a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing CABG with PCI in the modern stent era.
  
  
  METHODS
  We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from Jan 1, 1980, to March 12, 2013, for studies reported in English. Eligible studies were those in which investigators enrolled adult patients with diabetes and multivessel coronary artery disease, randomised them to CABG (with arterial conduits in at least 80% of participants) or PCI (with stents in at least 80% of participants), and reported outcomes separately in patients with diabetes, with a minimum of 12 months of follow-up. We used random-effects models to calculate risk ratios (RR) and 95% CIs for pooled data. We assessed heterogeneity using I(2). The primary outcome was all-cause mortality in patients with diabetes who had CABG compared with those who had PCI at 5-year (or longest) follow-up.
  
  
  RESULTS
  The initial search strategy identified 3414 citations, of which eight trials were eligible. These eight trials included 7468 participants, of whom 3612 had diabetes. Four of the RCTs used bare metal stents (BMS; ERACI II, ARTS, SoS, MASS II) and four used drug-eluting stents (DES; FREEDOM, SYNTAX, VA CARDS, CARDia). At mean or median 5-year (or longest) follow-up, individuals with diabetes allocated to CABG had lower all-cause mortality than did those allocated to PCI (RR 0.67, 95% CI 0.52-0.86; p=0.002; I(2)=25%; 3131 patients, eight trials). Treatment effects in individuals without diabetes showed no mortality benefit (1.03, 0.77-1.37; p=0.78; I(2)=46%; 3790 patients, five trials; p interaction=0.03). We identified no differences in outcome whether PCI was done with BMS or DES. When present, we identified no clear causes of heterogeneity.
  
  
  CONCLUSIONS
  In the modern era of stenting and optimum medical therapy, revascularisation of patients with diabetes and multivessel disease by CABG decreases long-term mortality by about a third compared with PCI using either BMS or DES. CABG should be strongly considered for these patients.
authors.affiliation: Division of Cardiac Surgery, St Michael's Hospital Toronto, ON, Canada; Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital Toronto, ON, Canada; Department of Surgery, University of Toronto, ON, Canada. Electronic address: vermasu@smh.ca.
authors.forename: Subodh
authors.initials: S
authors.lastname: Verma
authors.affiliation: Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital Toronto, ON, Canada; University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, ON, Canada.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Farkouh
authors.affiliation: Department of Surgery, University of Toronto, ON, Canada.
authors.forename: Bobby
authors.initials: B
authors.lastname: Yanagawa
authors.affiliation: Division of Cardiology, St Michael's Hospital Toronto, ON, Canada; Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital Toronto, ON, Canada; Department of Medicine, University of Toronto, ON, Canada.
authors.forename: David H
authors.initials: DH
authors.lastname: Fitchett
authors.affiliation: Division of Cardiac Surgery, St Michael's Hospital Toronto, ON, Canada.
authors.forename: Muhammad R
authors.initials: MR
authors.lastname: Ahsan
authors.affiliation: University of Ottawa Heart Institute, Ottawa, ON, Canada.
authors.forename: Marc
authors.initials: M
authors.lastname: Ruel
authors.affiliation: Department of Medicine, University of Toronto, ON, Canada; Division of Critical Care, Department of Medicine, Trillium Health Partners, Mississauga, ON, Canada.
authors.forename: Sachin
authors.initials: S
authors.lastname: Sud
authors.affiliation: Division of Cardiac Surgery, St Michael's Hospital Toronto, ON, Canada; Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital Toronto, ON, Canada; Department of Medicine, University of Toronto, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
authors.forename: Milan
authors.initials: M
authors.lastname: Gupta
authors.affiliation: Pramukhswami Medical College, Gujarat, India.
authors.forename: Shantanu
authors.initials: S
authors.lastname: Singh
authors.affiliation: Division of Cardiac Surgery, St Michael's Hospital Toronto, ON, Canada; University of Ottawa Heart Institute, Ottawa, ON, Canada.
authors.forename: Nandini
authors.initials: N
authors.lastname: Gupta
authors.affiliation: Division of Cardiology, St Michael's Hospital Toronto, ON, Canada; Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital Toronto, ON, Canada; Department of Medicine, University of Toronto, ON, Canada.
authors.forename: Asim N
authors.initials: AN
authors.lastname: Cheema
authors.affiliation: Division of Endocrinology and Metabolism, St Michael's Hospital Toronto, ON, Canada; Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital Toronto, ON, Canada; Department of Medicine, University of Toronto, ON, Canada; Department of Nutritional Sciences, University of Toronto, ON, Canada.
authors.forename: Lawrence A
authors.initials: LA
authors.lastname: Leiter
authors.affiliation: Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
authors.forename: Paul W M
authors.initials: PW
authors.lastname: Fedak
authors.affiliation: Division of Cardiac Surgery, St Michael's Hospital Toronto, ON, Canada; Division of Endocrinology and Metabolism, St Michael's Hospital Toronto, ON, Canada; Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital Toronto, ON, Canada.
authors.forename: Hwee
authors.initials: H
authors.lastname: Teoh
authors.affiliation: Division of Cardiac Surgery, St Michael's Hospital Toronto, ON, Canada; Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital Toronto, ON, Canada; Department of Surgery, University of Toronto, ON, Canada.
authors.forename: David A
authors.initials: DA
authors.lastname: Latter
authors.affiliation: Mount Sinai Medical Center, New York, NY, USA; National Center for Cardiovascular Research (CNIC), Madrid, Spain.
authors.forename: Valentin
authors.initials: V
authors.lastname: Fuster
authors.affiliation: Departments of Critical Care and Medicine, St Michael's Hospital Toronto, ON, Canada; Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital Toronto, ON, Canada; Department of Medicine, University of Toronto, ON, Canada; Interdepartmental Division of Critical Care, University of Toronto, ON, Canada. Electronic address: j.friedrich@utoronto.ca.
authors.forename: Jan O
authors.initials: JO
authors.lastname: Friedrich
mesh_terms: D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality*; D003327:Coronary Disease / Q000401:mortality* / Q000601:surgery*; D003920:Diabetes Mellitus / Q000401:mortality* / Q000601:surgery*; D006801:Humans; D062645:Percutaneous Coronary Intervention / Q000379:methods / Q000401:mortality*; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic / Q000379:methods / Q000401:mortality; D016896:Treatment Outcome