Clinical outcome comparison of percutaneous coronary intervention and bypass surgery in diabetic patients with coronary artery disease: a meta-analysis of randomized controlled trials and observational studies

Chuannan Zhai,Yingyi Zhang,Kai Hou,Hongliang Cong,Jingxia Zhang,Yuecheng Hu

doi:10.1186/s13098-019-0506-y

Chuannan Zhai, Yingyi Zhang + Show 4 more

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https://doi.org/10.1186/s13098-019-0506-y

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Abstract

BackgroundThe optimal revascularization technique in diabetic patients with complex coronary artery disease (CAD), including left main CAD and multivessel coronary disease (MVD), remains controversial. The current study aimed to compare adverse clinical endpoints of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM).MethodsRelevant studies were found from MEDLINE, OVID, Science Direct, Embase and the Cochrane Central database from January 2010 to April 2019. Risk ratio (RR) with 95% confidence interval (CI) was used to express the pooled effect on discontinuous variables. Outcomes evaluated were all-cause mortality, major adverse cardiac/cerebrovascular events (MACCE), cardiac death, myocardial infarction, stroke, and repeat revascularization.ResultsSixteen studies were included (18,224 patients). PCI was associated with the increase risk for MACCE (RR 1.59, 95% CI 1.38–1.85), cardiac death (RR 1.76, 95% CI 1.11–2.80), MI (RR 1.98, 95% CI 1.53–2.57), repeat revascularization (RR 2.61, 95% CI 2.08–3.29). The risks for all-cause mortality (RR 1.23, 95% CI 1.00–1.52) and stroke (RR 0.71, 95% CI 0.48–1.03) were similar between two strategies. Stratified analysis based on studies design and duration of follow-up showed largely similar findings with the overall analyses, except for a significant increased risk of all-cause mortality (RR 1.32, 95% CI 1.04–1.67) in long-term group, and CABG was associated with a higher stroke rate compared to PCI, which are results that were found in RCTs (RR 0.47, 95% CI 0.28–0.79) and mid-term groups (RR 0.39, 95% CI 0.23–0.66).ConclusionsCABG was superior to PCI for diabetic patients with complex CAD (including left main CAD and/or MVD), but might be associated with a higher risk of stroke mid-term follow-up.Number of Protocol registration PROSPERO CRD 42019138505.

Highlights

The optimal revascularization technique in diabetic patients with complex coronary artery disease (CAD), including left main CAD and multivessel coronary disease (MVD), remains controversial
Inclusion criteria Inclusion criteria were as follows: (1) types of studies: we included all randomized controlled trials (RCTs) and observational studies (OS); (2) types of participants: all patients with diabetes mellitus (DM) included in studies were diagnosed with left main CAD, MVD, or both; (3) types of interventions: all patients underwent direct percutaneous coronary intervention (PCI) or coronary artery bypass grafting surgery (CABG); and (4) outcomes: the incidence of all-cause mortality of patients underwent PCI, comparison to patients with CABG
HTN hypertension, Dsl dyslipidemia, P/C percutaneous coronary intervention versus coronary artery bypass surgery, DES drug-eluting stents, but type of the stents is not available, SES sirolimus-eluting stent, PES paclitaxel-eluting stent, EES everolimus-eluting stent, MVD multivessel disease, LM left main, RCTrandomized controlled trials, OS observational studies, NA not available follow-up (RR 2.56, 95% confidence interval (CI) 2.02–3.24, P < 0.001); Fig. 9a, b]

Summary

Introduction

The optimal revascularization technique in diabetic patients with complex coronary artery disease (CAD), including left main CAD and multivessel coronary disease (MVD), remains controversial. The current study aimed to compare adverse clinical endpoints of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM). Coronary artery bypass grafting (CABG) has been recommended as the standard of care for patients with diabetes and complex anatomic diseases, including left main CAD [5]. A number of clinical studies have been conducted globally to estimate and compare the clinical effects and end-point outcomes of the two approaches in an effort to determine the best revascularization strategy for patients with DM and complex CAD [8,9,10,11]

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