Recently published guidelines, based on the results of widely available meta-analyses and large clinical trials, including BARI-2D, SYNTAX, CARDia, FREEDOM, allow us to compare both types of revascularization-percutaneous and surgical- in diabetics [
30]. According to these recommendations, CABG remains the therapeutic strategy of choice for multivessel or complex (SYNTAX score >22) CAD in diabetic people. A considerable amount of evidence indicates that PCI is associated with a higher risk of repeat revascularization. On the other hand, CABG is connected with a higher risk of stroke. Nevertheless, FREEDOM trial [
33] proved that all-cause mortality and myocardial infarction rate were significantly lower in the case of surgical revascularization, despite preserved current pharmacological regimens and drug eluting stents (DES) usage. The inferiority of PCI in multivessel or complex CAD was claimed to be dependent on the usage of a previous stent generation. In order to exclude the influence of a stent type, two large trials were conducted. According to the BEST trial, in patients with diabetes, the prevalence of a primary composite end point was significantly higher in the group treated with PCI, than in patients assigned to CABG [
34]. The prevalence of both target-vessel and new lesion repeat revascularization, as well as the incidence of a major secondary composite end point, was higher in the PCI group, in a 2-year follow-up [
34]. The significance maintained in the long-term follow-up [
34]. In the second trial, Bangalore et al. [
35] showed a better outcome for PCI in a 30-day observation, in respect of a lower mortality and stroke incidence. The difference between stroke incidence in the PCI and CABG group was no longer significant after 30-days from the index procedure. The mortality rate also became similar in both groups, in the long-term follow-up. However, the prevalence of myocardial infarction, especially spontaneous, and repeat revascularization was significantly higher for patients, treated with PCI. The difference was noted already in the short-term follow-up, and maintained. These post-procedural complications, particularly concerned patients with incomplete revascularization [
35]. In an earlier study, comparing both strategies of revascularization in patients with resistant angina and high operative risk (EF < 35%, reoperation, MI < 7 days, IABP, age > 70 years), no difference was revealed [
36].
Despite the choice of a therapeutic intervention, a prompt diagnosis of cardiac ischemia is the crucial factor, that could improve the clinical outcome in diabetics. An early CAD diagnosis would facilitate the complete, arterial revascularization. We suppose that accurate revascularization, in addition to a continuous, satisfying glycaemic control and pharmacotherapy, can improve the poor prognosis of a diabetic patient. Accurate revascularization, meaning by-passing right lesions (corresponding with an ischemic segment) and all lesions, using preferably arterial grafts.