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Coronary artery ectasia (CAE) is a coronary abnormality characterized by arterial dilation, with inflammation, hypertension, dyslipidemia, and diabetes hypothesized to be implicated in its pathogenesis. The exact relationship between CAE and diabetes remains unclear, with previous studies reporting contradictory findings. We conducted a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO: CRD42024627403). Four databases (PubMed, Scopus, Web of Science, and Embase) were searched up to October 2024. Eligible studies included angiographically diagnosed CAE cases and controls with reported diabetes prevalence. Relative risks (RR) were calculated for diabetes, hypertension, and dyslipidemia; mean differences for body mass index and fasting blood sugar. Subgroup analyses compared isolated versus nonisolated CAE. Forty-six studies consisting of 6215 CAE patients and 59,484 non-CAE controls were included. Pooled results showed no significant association between diabetes and CAE (RR, 1.00; 95% CI, 0.88-1.13; I2, 76.65%; P = 0.95). Subgroup analyses showed no association in isolated CAE (RR,= 1.10; 95% CI, 0.92-1.32; I2, 50.45%; P = 0.31) or nonisolated CAE (RR, 0.84; 95% CI, 0.68-1.04; I2, 82.31%; P = 0.12). Fasting blood sugar analysis showed no significant difference between CAE and controls (mean differences, 2.43; 95% CI, -1.15 to 6.02; I2, 50.60%; P = 0.18). While diabetes is a well-established risk factor for atherosclerotic coronary disease, our pooled evidence indicates its contribution to ectatic changes is limited and not associated with CAE.