Impact of Diabetic Status on Outcomes After Revascularization With Drug-Eluting Stents in Relation to Coronary Artery Disease Complexity

Background— Diabetes mellitus and angiographic coronary artery disease complexity are intertwined and unfavorably affect prognosis after percutaneous coronary interventions, but their relative impact on long-term outcomes after percutaneous coronary intervention with drug-eluting stents remains controversial. This study determined drug-eluting stents outcomes in relation to diabetic status and coronary artery disease complexity as assessed by the Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score. Methods and Results— In a patient-level pooled analysis from 4 all-comers trials, 6081 patients were stratified according to diabetic status and according to the median SYNTAX score ≤11 or >11. The primary end point was major adverse cardiac events, a composite of cardiac death, myocardial infarction, and clinically indicated target lesion revascularization within 2 years. Diabetes mellitus was present in 1310 patients (22%), and new-generation drug-eluting stents were used in 4554 patients (75%). Major adverse cardiac events occurred in 173 diabetics (14.5%) and 436 nondiabetic patients (9.9%; P <0.001). In adjusted Cox regression analyses, SYNTAX score and diabetes mellitus were both associated with the primary end point ( P <0.001 and P =0.028, respectively; P for interaction, 0.07). In multivariable analyses, diabetic versus nondiabetic patients had higher risks of major adverse cardiac events (hazard ratio, 1.25; 95% confidence interval, 1.03–1.53; P =0.026) and target lesion revascularization (hazard ratio, 1.54; 95% confidence interval, 1.18–2.01; P =0.002) but similar risks of cardiac death (hazard ratio, 1.41; 95% confidence interval, 0.96–2.07; P =0.08) and myocardial infarction (hazard ratio, 0.89; 95% confidence interval, 0.64–1.22; P =0.45), without significant interaction with SYNTAX score ≤11 or >11 for any of the end points. Conclusions— In this population treated with predominantly new-generation drug-eluting stents, diabetic patients were at increased risk for repeat target-lesion revascularization consistently across the spectrum of disease complexity. The SYNTAX score was an independent predictor of 2-year outcomes but did not modify the respective effect of diabetes mellitus. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifiers: NCT00297661, NCT00389220, NCT00617084, and NCT01443104.