CABG associated with decreased mortality compared to stenting in diabetic patients

1. According to a meta-analysis of coronary revascularization techniques in diabetics, coronary artery bypass grafting (CABG) was associated with decreased mortality rates compared to percutaneous coronary interventions (PCI).

2. CABG was associated with higher risk of strokes than PCI.

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Cardiac disease is the most common cause of death among diabetics, and diabetics form a large proportion of patients who undergo coronary artery revascularization each year. Despite the substantial research regarding the use of stents to open narrowed arteries or bypass grafting to divert bloodflow, the best revascularization method remains unclear in diabetic patients. This study analyzed results from trials comparing percutaneous coronary interventions (PCI) with coronary artery bypass grafting (CABG) specifically in patients with diabetes. When data from these trials were combined in a meta-analysis, CABG was found to be associated with decreased mortality rates compared to PCI, as well as a decrease in a composite outcome of mortality, heart attack and stroke in patients with diabetes. Notably, when risk of stroke was analyzed separately from mortality and heart attacks, CABG was found to be associated with increased risk of stroke compared to PCI. Although this study incorporated results from several trials, a single, large trial may have highly influenced the results of the analysis, potentially limiting the strength of the results. Nevertheless, the analysis confirms prior results suggesting that CABG is associated with improved mortality outcomes compared to PCI in diabetic patients.

Click to read the study, published today in Annals of Internal Medicine

Relevant Reading: Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies

In-Depth [systematic review and meta-analysis]: This network meta-analysis examined results from 40 trials evaluating revascularization procedures in diabetics with angina and multivessel or left main coronary artery disease. Included studies compared either bare metal stents (PCI-BMS) or drug eluting stents (PCI-DES) with CABG, or compared PCI-BMS with PCI-DES to establish the analysis. The network meta-analysis approach, incorporating evidence on the relationship between PCI-BMS and PCI-DES, facilitated analysis of studies that took place over a number of years during which both CABG and PCI procedures evolved, and during which PCI transitioned from reliance upon BMS to frequent use of DES. Overall, compared to CABG, PCI was found to be associated with mildly increased odds of a combined mortality/myocardial infarction/stroke endpoint (OR 1.33; 95%CrI 1.01–1.65) and mortality (OR 1.44; 95%CrI 1.05–1.91), but decreased odds of stroke (OR 0.56; 95%CrI 0.38–0.88). Despite these results, the decreased odds of stroke associated with PCI highlights the continued need for individualized clinical judgment when recommending revascularization procedures for patients with diabetes.

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