title: Prolonged effectiveness of coronary artery bypass surgery versus drug-eluting stents in diabetics with multi-vessel disease: an updated systematic review and meta-analysis.
abstract: BACKGROUND
  Currently, the appropriateness of percutaneous coronary intervention (PCI) using drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) for patients with diabetes (DM) and multi-vessel disease (MVD) is uncertain due to limited evidence from few randomised controlled trials (RCTs). We aimed to compare the clinical effectiveness of CABG versus PCI-DES in DM-MVD patients using an evidence-based approach.
  
  
  METHODS
  A systematic review and meta-analyses were conducted to compare the risk of all-cause mortality, myocardial infarction (MI), repeat revascularisation, cerebrovascular events (CVE), and major adverse cardiac or cerebrovascular events (MACCE).
  
  
  RESULTS
  A total of 1,837 and 3,052 DM-MVD patients were pooled from four RCTs (FREEDOM, SYNTAX, VA CARDS, and CARDia) and five non-randomised studies. At mean follow-up of 3 years, CABG compared with PCI-DES was associated with a lower risk of all-cause mortality and MI in RCTs. By contrast, no significant differences were observed in the mean 3.5-year risk of all-cause mortality and MI in non-randomised trials. However, the risk of repeat revascularisations following PCI-DES compared with CABG was 2.3 (95% CI=1.8-2.8) and 3.0 (2.3-4.2)-folds higher in RCTs and non-randomised trials, respectively. Accordingly, the risk of MACCE at 3 years following CABG compared with PCI-DES was lower in both RCTs and non-randomised trials [0.65 (: 0.55-0.77); and 0.77 (0.60-0.98), respectively].
  
  
  CONCLUSIONS
  Based on our pooled results, we recommend CABG compared with PCI-DES for patients with DM-MVD. Although non-randomised trials suggest no additional survival-, MI-, and CVE- benefit from CABG over PCI-DES, these results should be interpreted with care.
authors.affiliation: Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, VIC, Australia.
authors.forename: Thathya V
authors.initials: TV
authors.lastname: Ariyaratne
authors.affiliation: Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, VIC, Australia; Melbourne Epi Centre, Department of Medicine, The University of Melbourne, Parkville, VIC, Australia.
authors.forename: Zanfina
authors.initials: Z
authors.lastname: Ademi
authors.affiliation: Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, VIC, Australia; Cardiothoracic Unit, Geelong Hospital, Geelong, VIC, Australia.
authors.forename: Cheng-Hon
authors.initials: CH
authors.lastname: Yap
authors.affiliation: Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, VIC, Australia.
authors.forename: Baki
authors.initials: B
authors.lastname: Billah
authors.affiliation: Cardiac Surgical Research Unit, Department of Cardiothoracic Surgery, Alfred Hospital, Department of Surgery, Monash University, Melbourne, VIC, Australia.
authors.forename: Frank
authors.initials: F
authors.lastname: Rosenfeldt
authors.affiliation: Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, and the Chinese University of Hong Kong, Hong Kong.
authors.forename: Bryan P
authors.initials: BP
authors.lastname: Yan
authors.affiliation: Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, VIC, Australia. Electronic address: chris.reid@monash.edu.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Reid
mesh_terms: D002986:Clinical Trials as Topic / Q000639:trends; D001026:Coronary Artery Bypass / Q000639:trends*; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000628:therapy*; D054855:Drug-Eluting Stents / Q000639:trends*; D006801:Humans; D062645:Percutaneous Coronary Intervention / Q000295:instrumentation / Q000639:trends*; D013997:Time Factors; D016896:Treatment Outcome
keywords: Clinical outcomes; Coronary artery bypass grafting; Drug-eluting stents; Effectiveness; Percutaneous coronary intervention