Original title: Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: A meta-analysis of randomized controlled trials. Reference: Verma S. et al. Lancet Diabetes Endocrinol. 2013;Epub ahead of print.

The FREEDOM study was the last of the randomized studies that compared the results of surgery versus coronary angioplasty in diabetic multivessel patients showing a reduction in the relative risk of death, heart attack and stroke by 30% in favor of surgery. While the results of this work were clear, previous studies still left some room for doubt, especially for hard endpoints such as death. 

This study is a meta-analysis of 8 randomized controlled trials in diabetic multivessel patients to surgery or angioplasty. Of all the studies analyzed, 4 used stents (ERACI II, ARTS, SoS and MASS II) and the other 4 used, drug-eluting stents (FREEDOM, SYNTAX, and VA CARDS CARDia). 

At 5 years follow-up  a lower mortality rate was observed with surgery (RR 0.67, CI 0.52 to 0.86, P = 0.002) that was not evident at one year (RR 0.99, CI 0.72 to 1.37, P = .97). The difference in mortality in favor of surgery was similar regardless of the type of stent used (BMS or DES). The rate of nonfatal myocardial infarction was similar both after a year as after five years between the two strategies (RR 1.01, P = 0.98 and RR 0.76, p = 0.3 respectively). The surgery was associated with an increased risk of stroke especially in following year (RR 2.4, P = 0.01 at one year and RR 1.72, P = 0.005 at 5 years). As expected, the greatest difference is given by the rate of revascularization that benefits surgery significantly from the start of monitoring (RR 0.36, p <0.0001 and RR 0.41, P <0.0001, respectively). According to this meta-analysis, the mortality difference disappears when comparing surgery and angioplasty in patients without diabetes (RR 1.03, CI 0.77 to 1.37, P = .78). 

Conclusion: 

Surgical revascularization of diabetic multivessel patients decreases long-term mortality by about one third compared with angioplasty beyond the type of stent used. 

Editorial Comment: 

Unfortunately it is not possible to analyze the anatomical complexity as the SYNTAX score was introduced after the publication of several of the studies analyzed. These findings do not necessarily have to lead to surgery for all diabetics since the presence of 3 vessels is quite heterogeneous. The team discussion of each particular case and the opinion of the patient are essential. 

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