Background The efficacy and safety of percutaneous coronary interventions (PCI) relative to coronary artery bypass grafting (CABG) in patients with diabetes and unprotected left main coronary artery disease (LMCAD) are not well established. Objectives To perform a meta‐analysis evaluating the long‐term outcomes after PCI with drug‐eluting stents (DES), as compared with CABG, in patients with diabetes and unprotected LMCAD. Methods MEDLINE, Cochrane, and Embase were searched for randomized controlled trials (RCTs) that reported outcomes after PCI with DES versus CABG in unprotected LMCAD among patients with diabetes. To evaluate the long‐term effects of these interventions, we restricted this analysis to studies with a minimum follow‐up period of 3 years. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled with a random‐effects model. Quality assessment and risk of bias were performed according to Cochrane recommendations. Results Four RCTs with a total of 1080 patients were included, 553 (51.2%) of whom underwent PCI. There was no difference for individual outcomes of all‐cause mortality (RR: 1.21; 95% CI: 0.86–1.71; p = .27; I2 = 28%), cardiovascular death (RR 1.29; 95% CI: 0.76–2.18; p = .34; I2 = 0%), or myocardial infarction (MI) (RR: 0.94; 95% CI: 0.61–1.45; p = .79; I2 = 0%). However, the risk of stroke was reduced with PCI relative to CABG (RR: 0.41; 95% CI: 0.18–0.94; p = .04; I2 = 0%), whereas the risk of any repeat revascularization was higher in the PCI group (RR: 1.99; 95% CI: 1.44–2.75; p < .001; I2 = 0%). The risk of the composite outcome of all‐cause mortality, MI, stroke, or repeat revascularization was higher after PCI compared with CABG (RR: 1.30; 95% CI: 1.09–1.56; p = .004; I2 = 0%). Conclusion In this meta‐analysis with more than 1000 patients with diabetes and unprotected LMCAD followed for a minimum of 3 years, the incidence of repeat revascularization was higher among those treated with PCI, whereas the risk of stroke was higher in patients treated with CABG.

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