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Lancet Diabetes Endocrinol. 2013 Dec;1(4):317-28. doi: 10.1016/S2213-8587(13)70089-5. Epub 2013 Sep 13.

Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised controlled trials.

Author information

1
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.
2
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.
3
Department of Surgery, University of Toronto, ON, Canada.
4
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.
5
Division of Cardiac Surgery, St Michael's Hospital Toronto, ON, Canada.
6
University of Ottawa Heart Institute, Ottawa, ON, Canada.
7
Department of Medicine, University of Toronto, ON, Canada; Division of Critical Care, Department of Medicine, Trillium Health Partners, Mississauga, ON, Canada.
8
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.
9
Pramukhswami Medical College, Gujarat, India.
10
Division of Cardiac Surgery, St Michael's Hospital Toronto, ON, Canada; University of Ottawa Heart Institute, Ottawa, ON, Canada.
11
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.
12
Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
13
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.
14
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.
15
Mount Sinai Medical Center, New York, NY, USA; National Center for Cardiovascular Research (CNIC), Madrid, Spain.
16
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.

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.

FINDINGS:

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.

INTERPRETATION:

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.

Comment in

PMID:
24622417
DOI:
10.1016/S2213-8587(13)70089-5
[Indexed for MEDLINE]

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