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Coronary Revascularization in Diabetic Patients: A Systematic Review and Bayesian Network Meta-analysisCoronary Revascularization in Diabetic Patients

Benny Tu, MBBS; Ben Rich, PhD; Christopher Labos, MD, CM, MSc; and James M. Brophy, MD, PhD
[+] Article, Author, and Disclosure Information

From the University of Queensland, Brisbane, Queensland, Australia, and McGill University and McGill University Health Center, Montréal, Québec, Canada.

Financial Support: Dr. Brophy receives a salary and operating support from the Fonds de recherche du Québec-Santé, a nonprofit provincial funding agency.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0808.

Requests for Single Reprints: James M. Brophy, MD, PhD, McGill University Health Center, Royal Victoria Hospital, 687 Pine Avenue West, Ross 4.12, Montréal, Québec H3A 1A1, Canada; e-mail, james.brophy@mcgill.ca.

Current Author Addresses: Dr. Tu: Medical Services, Executive Suites, Greenslopes Private Hospital, Newdegate Street, Greenslopes, Queensland 4120, Australia.

Dr. Rich: McGill University Health Center, Royal Victoria Hospital, 687 Pine Avenue West, Ross 4.14, Montréal, Québec H3A 1A1, Canada.

Dr. Labos: McGill University Health Center, Royal Victoria Hospital, 687 Pine Avenue West, Room 4M.76, Montréal, Québec H3A 1A1, Canada.

Dr. Brophy: McGill University Health Center, Royal Victoria Hospital, 687 Pine Avenue West, Ross 4.12, Montréal, Québec H3A 1A1, Canada.

Author Contributions: Conception and design: B. Tu, J.M. Brophy.

Analysis and interpretation of the data: B. Tu, B. Rich, C. Labos, J.M. Brophy.

Drafting of the article: B. Tu, B. Rich, C. Labos, J.M. Brophy.

Critical revision of the article for important intellectual content: B. Tu, B. Rich, C. Labos, J.M. Brophy.

Final approval of the article: B. Tu, B. Rich, C. Labos, J.M. Brophy.

Provision of study materials or patients: B. Tu.

Statistical expertise: B. Tu, B. Rich, C. Labos, J.M. Brophy.

Obtaining of funding: J.M. Brophy.

Administrative, technical, or logistic support: B. Tu.

Collection and assembly of data: B. Tu, B. Rich, C. Labos, J.M. Brophy.


Ann Intern Med. 2014;161(10):724-732. doi:10.7326/M14-0808
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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 bare-metal 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 long-term 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.

Primary Funding Source: Fonds de recherche du Québec-Santé.

Figures

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Appendix Figure 1.

Summary of evidence search and selection for PCI-DES versus CABG.

CABG = coronary artery bypass grafting; DES = drug-eluting stent; DM = diabetes mellitus; MVD = multivessel disease; PCI-DES = percutaneous coronary intervention with drug-eluting stents; RCT = randomized, controlled trial.

* Not an RCT.

† 7 studies.

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Appendix Figure 2.

Summary of evidence search and selection for PCI-BMS versus CABG.

BMS = bare-metal stent; CABG = coronary artery bypass grafting; DM = diabetes mellitus; MVD = multivessel disease; PCI-BMS = percutaneous coronary intervention with bare-metal stents; RCT = randomized, controlled trial.

* Not an RCT.

† 6 studies.

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Appendix Figure 3.

Summary of evidence search and selection for PCI-BMS versus PCI-DES.

AMI = acute myocardial infarction; BMS = bare-metal stent; DES = drug-eluting stent; DM = diabetes mellitus; MVD = multivessel disease; PCI-BMS = percutaneous coronary intervention with bare-metal stents; PCI-DES = percutaneous coronary intervention with drug-eluting stents; RCT = randomized, controlled trial; STEMI = ST-segment elevation myocardial infarction.

* Not an RCT.

† 27 studies.

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Figure 1.

Network meta-analysis schematic.

BMS = bare-metal stent; CABG = coronary artery bypass grafting; DES = drug-eluting stent.

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Figure 2.

Summary of risk of bias using the Cochrane risk-of-bias tool.

BMS = bare-metal stent; CABG = coronary artery bypass grafting; DES = drug-eluting stent.

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Figure 3.

Composite end point of all-cause mortality, MI, and stroke.

BMS = bare-metal stent; CABG = coronary artery bypass grafting; DES = drug-eluting stent; MI = myocardial infarction; OR = odds ratio.

* OR (95% credible interval).

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Figure 4.

All-cause mortality.

BMS = bare-metal stent; CABG = coronary artery bypass grafting; DES = drug-eluting stent; OR = odds ratio.

* OR (95% credible interval).

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Appendix Figure 4.

Cases of MI.

BMS = bare-metal stent; CABG = coronary artery bypass grafting; DES = drug-eluting stent; MI = myocardial infarction; OR = odds ratio.

* OR (95% credible interval).

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Appendix Figure 5.

Cases of revascularization.

BMS = bare-metal stent; CABG = coronary artery bypass grafting; DES = drug-eluting stent; OR = odds ratio.

* OR (95% credible interval).

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Appendix Figure 6.

Cases of stroke.

CABG = coronary artery bypass grafting; DES = drug-eluting stent; OR = odds ratio.

* OR (95% credible interval).

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Appendix Figure 7.

Cases of MACCEs.

BMS = bare-metal stent; CABG = coronary artery bypass grafting; DES = drug-eluting stent; MACCE = major adverse cardiovascular and cerebrovascular event; OR = odds ratio.

* OR (95% credible interval).

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