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

Abstract

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 ( RCT s). Methods and Results: RCT s comparing PCI with DES versus CABG in diabetic patients with MVD who met inclusion criteria were analyzed (protocol registration No. CRD 42013003693). 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 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.