FRANCO Julia (2), SURUAGY-MOTTA Ricardo (1), FRANCO Julia (2), ISHIZUKA Bruno (3), OHANNESIAN Victor (3), AGRA SILVA Julia (1), RAJCHENBERG Diego (4), DANTAS Viviane (5), ORNELAS PINTO Eduarda (6), MARTINS FILHO Evandro (7), AZZALINI Lorenzo (8), KUMAR Sant (8)
(1) Cesmac Campus I, State of Alagoas, BRAZIL; (2) PUC PR, State of Paraná, BRAZIL; (3) Einstein Hospital Israelita – Complexo Morumbi, State of São Paulo, BRAZIL; (4) University of Vale do Rio dos Sinos Campus São Leopoldo, RS, BRAZIL; (5) Universidade Católica de Brasília - Câmpus Taguatinga, Federal District, BRAZIL; (6) University Park, State of Minas Gerais, BRAZIL; (7) Santa Casa de Misericórdia de Maceió, State of Alagoas, BRAZIL; (8) University of Washington, WA, UNITED STATES
AIMS
This study aims to evaluate the effect of DM on clinical outcomes in patients undergoing PCI for LM bifurcation lesions through a systematic review and meta-analysis.
METHODS AND RESULTS
Methods We performed a systematic review and meta-analysis in strict accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The protocol was prospectively registered in the PROSPERO database. A comprehensive electronic search was conducted across PubMed, the Cochrane Library, Web of Science, and Scopus for studies published through August 2025. We included observational studies and clinical trials that directly compared clinical outcomes between DM and non-DM patients undergoing PCI for LM bifurcation lesions. The primary efficacy endpoint was the incidence of Major Adverse Cardiovascular Events (MACE). Secondary endpoints included all-cause mortality, cardiac death, myocardial infarction (MI), and target lesion revascularization (TLR). Statistical analysis was executed using a random-effects model to account for inter-study variability. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using R software. Temporal trends were assessed across follow-up intervals ranging from 9 months to 5 years.
Results
A total of six studies encompassing 12,494 patients were included in the final analysis. The prevalence of DM in the studied cohorts was notably high, ranging from 33% to 50%, reflecting the significant burden of metabolic disease in patients with complex coronary anatomy. Our results demonstrate that DM is a consistent and powerful predictor of adverse outcomes following LM bifurcation PCI. Patients with DM exhibited a significantly higher risk of MACE between 9 months and 2 years (RR range 1.73–1.92). The risk of MI remained elevated throughout the mid-to-long term, with a nearly two-fold increase observed for up to 5 years (RR range 1.90–2.16). Furthermore, DM was associated with significantly higher cardiac mortality at the 9-month mark (RR 1.96) and a marked increase in the need for TLR between 9 months and 2 years (RR range 1.61–1.82). Notably, there was no statistically significant association between DM status and the risk of definite/probable stent thrombosis, suggesting that the excess in ischemic events may be driven more by progressive neoatherosclerosis and non-target lesion failure than by acute device-related complications.
CONCLUSIONS
In patients undergoing PCI for LM bifurcation lesions, Diabetes Mellitus is a robust and independent predictor of significantly worse long-term clinical outcomes. Despite the utilization of modern DES and optimized procedural techniques, diabetic patients experience higher rates of MACE, myocardial infarction, cardiac death, and repeat revascularization. These findings underscore the inherent limitations of mechanical revascularization alone in this population and highlight the urgent necessity for aggressive secondary prevention, optimized glycemic control, and potentially tailored procedural strategies, such as the routine use of intravascular imaging, to mitigate the heightened ischemic risk associated with DM in complex coronary interventions.
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