IJCS | Volume 31, Nº2, March / April 2018

159 Andrade et al. Stent versus surgery: randomized trials Int J Cardiovasc Sci. 2018;31(2)152-162 Original Article Table 1 – Overview of randomized studies comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in the era of drug-eluting stents Study Origin Year of publication Number of patients Disease extension Patients with diabetes(%) Unstable angina(%) Mean ejection fraction (%) Type of stent Follow-up Maximum LEMANS 1 Poland 2008 105 LMCA 25 32 53 ± 11 BMS and DES 10 SYNTAX 2 International 2009 1800 LMCA and three-vessel disease 35 28 ND ‡ SF 5 CARDia 4 United Kingdom 2010 510 Two- and three-vessel disease 100 22 59 ± 14 BMS and DES 5 Boudriot et al. 5 Germany 2011 201 LMCA 30 ND ND DES 1 PRECOMBAT 6 South Korea 2011 600 LMCA 42 45 60 ± 9 DES 5 FREEDOM 8 International 2012 1900 Two- and three-vessel disease 100 30 65 ± 12 DES 5 Va-Cards 7 USA 2013 198 Two- and three-vessel disease 100 ND ND† DES 2 BEST 9 South Korea 2015 880 Two- and three-vessel disease 45 42 59 ± 9 DES 5 EXCEL 11 International 2016 1905 LMCA 25 37 57 ± 10 DES 3 NOBLE 10 Europe 2016 982 LMCA 18 18 60 ± 10 DES 5 SYNTAX: Synergy between PCI with Taxus and Cardiac Surgery; CARDia: Coronary Artery Revascularization in Diabetes; LE MANS: Left Main Coronary Artery Stenting; FREEDOM: Future Revascularization Evaluation in Patients with Diabetes Mellitus; VA CARDS: Coronary Artery Revascularization in Diabetes; BEST: Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease; PRECOMBAT: Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease; EXCEL: Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; NOBLE: Nordic-Baltic-British Left Main Revascularization Study; Boudriot - study by Boudriot et al.: J Am Coll Cardiol. 2011; 57: 538-545; DES: drug-eluting stent; BMS: bare-metal stent; LMCA: left main coronary artery; USA: United States. †: 37% with ejection fraction < 55%; ‡: 3% with ejection fraction < 30%. findings of the BARI study. The investigators of this study evaluated a subgroup of 343 patients with diabetes and found a late mortality of 34.5% for PCI with balloon and 19.4% for surgery (p = 0.03). In the era of conventional stent, studies such as SoS and ARTS have confirmed a trend toward greater mortality with PCI in patients with diabetes, even though it did not reach statistical significance. From there onwards, the presence of diabetes has become a criterion for preferential indication of surgery as a method for myocardial revascularization. There used to be a hypothesis that drug-eluting stents would eliminate the differences in mortality found in these studies, but the results presented here demonstrate that the difference in mortality between PCI and surgery in patients with diabetes continues in the era of drug-eluting stents. However, it should be noted a reduced risk difference compared with previous studies (3.5% risk difference as opposed to 7.3% in the study by Hclatki et al. and 15.1% in BARI). This should raise the hypothesis that it is not the metabolic disorder in itself, but the complexity of the lesions which is the factor leading to a higher mortality of angioplasty in patients with diabetes. This question could perhaps be explained by a meta-analysis of individual patient data involving a large number of studies. In this sense, a recent collaborative study categorizing the results of three studies (SYNTAX, BEST, and PRECOMBAT) corroborated this hypothesis. 24