Meta-Analysis
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Nov 26, 2020; 12(11): 559-570
Published online Nov 26, 2020. doi: 10.4330/wjc.v12.i11.559
Medical therapy vs early revascularization in diabetics with chronic total occlusions: A meta-analysis and systematic review
Muhammad Shayan Khan, Farhad Sami, Hemindermeet Singh, Waqas Ullah, Ma'en Al-Dabbas, Khalid Hamid Changal, Tanveer Mir, Zain Ali, Ameer Kabour
Muhammad Shayan Khan, Internal Medicine, Mercy Saint Vincent Medical Centre, Toledo, OH 43608, United States
Farhad Sami, Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, 66202, United States
Hemindermeet Singh, Ma'en Al-Dabbas, Ameer Kabour, Department of Cardiovascular Fellowship, Mercy St Vincent Medical Center and Hospital, Toledo, OH 43608, United States
Waqas Ullah, Internal Medicine, Abington Jefferson Health, Abington, Abington Township, Montgomery County, PA 19001, United States
Khalid Hamid Changal, Department of Cardiovascular Medicine, University of Toledo, Toledo, OH 43606, United States
Tanveer Mir, Internal Medicine, Detroit Medical Center, Detroit, MI 48201, United States
Zain Ali, Internal Medicine, Abington Jefferson Health, Philadelphia, PA 19001, United States
Author contributions: Khan MS contributed to concept and design of the manuscript including the acquisition, analysis and interpretation of data as primary and corresponding author; Sami FA and Changal KH had substantial contributions to the conception or design of the work, provided the majority of images; Singh H, Ullah W, Al-Dabbas M contributed to the analysis of cases including drafting the work for important intellectual content; Mir T, Kabour A and Ali Z had substantial contributions to the conception or design of the work, provided the majority of images and drafted the work critically including the final version and agreed to be accountable for all aspects of the work. All authors revised the work critically including the final version and agreed to be accountable for all aspects of the work.
Conflict-of-interest statement: Authors report no conflict of interest.
PRISMA 2009 Checklist statement: The Authors have read the PRISMA checklist and the manuscript was prepared and revised according to the 2009 PRISMA check list.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Muhammad Shayan Khan, MBBS, MD, Doctor, Internal Medicine, Mercy Saint Vincent Medical Centre, 2213 Cherry Street, Toledo, OH 43608, United States. muhammadshayankhan1@gmail.com
Received: July 6, 2020
Peer-review started: July 6, 2020
First decision: September 17, 2020
Revised: September 30, 2020
Accepted: October 29, 2020
Article in press: October 29, 2020
Published online: November 26, 2020
Processing time: 142 Days and 13.1 Hours
ARTICLE HIGHLIGHTS
Research background

The thought process behind this manuscript was our motivation upon literature review of a scarcity of data involving clinical outcomes of diabetics with chronic total occlusion (CTO) of coronary vessels. 

Research motivation

Our motivation came from the scarcity of data in this sub group of population. There exists a lot of literature comparing the mortality and morbidity outcomes of medical therapy (OMT) vs early re-vascularization [ER: Percutaneous coronary intervention (PCI) + Coronary artery bypass grafting] in patients with chronic total occlusions but none in the diabetic subset. 

Research objectives

To compare the mortality and morbidity outcomes in diabetic population with CTO treated with OMT vs ER.

Research methods

Multiple electronic data-bases including Pubmed, Embase were searched involving human studies comparing OMT vs ER in patients having CTO of coronary vessels. Data was analyzed using Cochrane review manager with hazard ratios using the random effects model. Primary effect estimate was all cause mortality with secondary effect estimates as cardiac mortality, repeat myocardial infarction (MI) and repeat re-vascularization.

Research results

Statistical analysis revealed a higher risk for all-cause mortality, cardiac mortality and repeat re-vascularization in the OMT group. For repeat MI, data analysis revealed no significant differences in between the two groups. Sub-group analysis was also done for OMT vs PCI. This revealed a higher risk for all-cause mortality but not for cardiac mortality or repeat re-vascularization in the OMT group. Interestingly, patients in the OMT group were found to have a lower incidence of repeat MI vs PCI group. 

Research conclusions

There is a trend towards superiority of the ER group as compared to OMT group in diabetic patients with a CTO. These findings were reinforced on sub-group analysis of OMT vs PCI. 

Research perspectives

Despite our limitations, we present the first ever meta-analysis specifically involving diabetic patients only with CTO treated with OMT or ER. Although we were able to demonstrate a trend towards superiority of the ER group, this was not statistically significant for some sub-groups including all-cause and cardiac mortality. Although this manuscript provides a relatively new insight into management of such patients, further studies may be needed before a consensus is developed.