Thathya V Ariyaratne1, Zanfina Ademi2, Cheng-Hon Yap3, Baki Billah1, Frank Rosenfeldt4, Bryan P Yan5, Christopher M Reid6. 1. Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, VIC, Australia. 2. 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. 3. 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. 4. Cardiac Surgical Research Unit, Department of Cardiothoracic Surgery, Alfred Hospital, Department of Surgery, Monash University, Melbourne, VIC, Australia. 5. Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, and the Chinese University of Hong Kong, Hong Kong. 6. 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.
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.
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-MVDpatients 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-MVDpatients 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.