Coronary revascularization in diabetic patients: A systematic review and bayesian network meta-analysis

Abstract

Background: The optimal revascularization technique in diabetic patients is an important unresolved question. Purpose: To compare long-term outcomes between the revascularization techniques of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Data Sources: English-language publications in PubMed, the Cochrane Central Register of Controlled Trials, Ovid, and EMBASE between 1 January 1990 and 1 June 2014. Study Selection: Two investigators independently reviewed randomized, controlled trials comparing PCI (with drug-eluting or baremetal stents) with CABG in adults with diabetes with multivessel or left main coronary artery disease. Data Extraction: Study design, quality, patient characteristics, length of follow-up, and outcomes were extracted. For duplicate publications, outcomes were obtained from the publication with the longest follow-up. Data Synthesis: 40 studies were combined using a Bayesian network meta-analysis that accounted for the variation in stent choice. The primary outcome, a composite of all-cause mortality, nonfatal myocardial infarction, and stroke, increased with PCI (odds ratio [OR], 1.33 [95% credible interval {CrI}, 1.01 to 1.65]). Percutaneous coronary intervention resulted in increased mortality (OR, 1.44 [CrI, 1.05 to 1.91]), no change in the number of myocardial infarctions (OR, 1.33 [CrI, 0.86 to 1.95]), and fewer strokes (OR, 0.56 [CrI, 0.36 to 0.88]). Limitations: Study design and length of follow-up were heterogeneous, and results were driven primarily by a single study. Costs and nonvascular complications of the interventions were not examined. Conclusion: Coronary artery bypass grafting seems to be the preferred revascularization technique in diabetics, especially if longterm survival is anticipated. However, because of residual uncertainties and increased risk for stroke with CABG, clinical judgment is required when choosing a revascularization technique in patients with diabetes.