601
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Kimura T, Morimoto T, Furukawa Y, Nakagawa Y, Shizuta S, Ehara N, Taniguchi R, Doi T, Nishiyama K, Ozasa N, Saito N, Hoshino K, Mitsuoka H, Abe M, Toma M, Tamura T, Haruna Y, Imai Y, Teramukai S, Fukushima M, Kita T. Long-Term Outcomes of Coronary-Artery Bypass Graft Surgery Versus Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease in the Bare-Metal Stent Era. Circulation 2008; 118:S199-209. [DOI: 10.1161/circulationaha.107.735902] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Observational registries comparing coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) have reported long-term survival results that are discordant with those of randomized trials.
Methods and Results—
We conducted a multicenter study in Japan enrolling consecutive patients undergoing first CABG or PCI between January 2000 and December 2002. Among 9877 patients enrolled, 5420 (PCI: 3712, CABG: 1708) had multivessel disease without left main involvement. Because age is an important determinant when choosing revascularization strategies, survival analysis was stratified by either age ≥75 or <75 years. Analyses were also performed in other relevant subgroups. Median follow-up interval was 1284 days with 95% follow-up rate at 2 years. At 3 years, unadjusted survival rates were 91.7% and 89.6% in the CABG and PCI groups, respectively (log rank
P
=0.26). After adjustment for baseline characteristics, survival outcome tended to be better after CABG (hazard ratio for death after PCI versus CABG [HR], 95% confidence interval [CI]: 1.23 [0.99-1.53],
P
=0.06). Adjusted survival outcomes also tended to be better for CABG among elderly patients (HR [95%CI]: 1.37 [0.98-1.92]
P
=0.07), but not among nonelderly patients (HR [95% CI]: 1.09 [0.82-1.46],
P
=0.55). Unadjusted and adjusted survival outcome for CABG and PCI were not significantly different in any subgroups when elderly patients were excluded from analysis.
Conclusions—
In the CREDO-Kyoto registry, survival outcomes among patients <75 years of age were similar after PCI and CABG, a result that is consistent with those of randomized trials.
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Affiliation(s)
- Takeshi Kimura
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Takeshi Morimoto
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Yutaka Furukawa
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Yoshihisa Nakagawa
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Satoshi Shizuta
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Natsuhiko Ehara
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Ryoji Taniguchi
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Takahiro Doi
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Kei Nishiyama
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Neiko Ozasa
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Naritatsu Saito
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Kozo Hoshino
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Hirokazu Mitsuoka
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Mitsuru Abe
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Masanao Toma
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Toshihiro Tamura
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Yoshisumi Haruna
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Yukiko Imai
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Satoshi Teramukai
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Masanori Fukushima
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
| | - Toru Kita
- From the Department of Cardiovascular of Medicine (T. Kimura, H.M., T. Kita) and the Center for Medical Education (T.M.), Graduate School of Medicine, Kyoto University; the Division of Cardiology (Y.F., S.S., T.D., N.O., N.S., M.T., T.T.), Kyoto University Hospital; the Division of Cardiology (Y.N.), Tenri Hospital; the Division of Cardiology (N.E.), Kobe City Medical Center General Hospital; the Division of Cardiology (R.T.), Hyogo Prefectural Amagasaki Hospital; Emergency Medicine (K.N.), Kyoto
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602
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Windecker S, Serruys PW, Wandel S, Buszman P, Trznadel S, Linke A, Lenk K, Ischinger T, Klauss V, Eberli F, Corti R, Wijns W, Morice MC, di Mario C, Davies S, van Geuns RJ, Eerdmans P, van Es GA, Meier B, Jüni P. Biolimus-eluting stent with biodegradable polymer versus sirolimus-eluting stent with durable polymer for coronary revascularisation (LEADERS): a randomised non-inferiority trial. Lancet 2008; 372:1163-73. [PMID: 18765162 DOI: 10.1016/s0140-6736(08)61244-1] [Citation(s) in RCA: 494] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND A novel stent platform eluting biolimus, a sirolimus analogue, from a biodegradable polymer showed promising results in preliminary studies. We compared the safety and efficacy of a biolimus-eluting stent (with biodegradable polymer) with a sirolimus-eluting stent (with durable polymer). METHODS We undertook a multicentre, assessor-blind, non-inferiority study in ten European centres. 1707 patients aged 18 years or older with chronic stable coronary artery disease or acute coronary syndromes were centrally randomised by a computer-generated allocation sequence to treatment with either biolimus-eluting (n=857) or sirolimus-eluting (n=850) stents. The primary endpoint was a composite of cardiac death, myocardial infarction, or clinically-indicated target vessel revascularisation within 9 months. Analysis was by intention to treat. 427 patients were randomly allocated to angiographic follow-up, with in-stent percentage diameter stenosis as principal outcome measure at 9 months. The trial is registered with ClinicalTrials.gov, number NCT00389220. FINDINGS We analysed all randomised patients. Biolimus-eluting stents were non-inferior to sirolimus-eluting stents for the primary endpoint at 9 months (79 [9%] patients vs 89 [11%], rate ratio 0.88 [95% CI 0.64-1.19], p for non-inferiority=0.003, p for superiority=0.39). Frequency of cardiac death (14 [1.6%] vs 21 [2.5%], p for superiority=0.22), myocardial infarction (49 [5.7%] vs 39 [4.6%], p=0.30), and clinically-indicated target vessel revascularisation (38 [4.4%] vs 47 [5.5%], p=0.29) were similar for both stent types. 168 (79%) patients in the biolimus-eluting group and 167 (78%) in the sirolimus-eluting group had data for angiographic follow-up available. Biolimus-eluting stents were non-inferior to sirolimus-eluting stents in in-stent percentage diameter stenosis (20.9%vs 23.3%, difference -2.2% [95% CI -6.0 to 1.6], p for non-inferiority=0.001, p for superiority=0.26). INTERPRETATION Our results suggest that a stent eluting biolimus from a biodegradable polymer represents a safe and effective alternative to a stent eluting sirolimus from a durable polymer in patients with chronic stable coronary artery disease or acute coronary syndromes. FUNDING Biosensors Europe SA, Switzerland.
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Affiliation(s)
- Stephan Windecker
- Department of Cardiology, and CTU Bern, Bern University Hospital, Bern, Switzerland.
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603
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Byrne RA, Mehilli J, Iijima R, Schulz S, Pache J, Seyfarth M, Schömig A, Kastrati A. A polymer-free dual drug-eluting stent in patients with coronary artery disease: a randomized trial vs. polymer-based drug-eluting stents. Eur Heart J 2008; 30:923-31. [PMID: 19240066 DOI: 10.1093/eurheartj/ehp044] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Robert A Byrne
- ISAR Centre, Deutsches Herzzentrum, Technische Universität, Lazarettstrasse 36, 80636 Munich, Germany
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604
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Cai Q, Skelding K, Arthur A, Desai D, Wood GC, Blankenship J. Predictors of Long-Term Major Adverse Cardiac Events and Clinical Restenosis following Elective Percutaneous Coronary Stenting. Angiology 2008; 60:141-7. [DOI: 10.1177/0003319708321587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Limited data exist regarding the predictors of long-term clinical outcomes following elective percutaneous coronary intervention (PCI) in the current era of stenting. The authors investigated the predictors of major adverse cardiac events (MACE) and clinical restenosis in 740 consecutive patients who underwent successful elective PCI with bare metal stents (BMSs) or drug-eluting stents (DESs). At 30-month follow -up, compared with BMS recipients, DES recipients had a significantly lower rate of MACE, which was mainly driven by a decreased repeat target vessel PCI. The rate of 30-month clinical restenosis was significantly lower in DES recipients. The authors conclude that baseline clinical, angiographic, and procedural characteristics determine long-term MACE and clinical restenosis after elective PCI, with DES being the independent predictor for both.
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Affiliation(s)
- Qiangjun Cai
- Department of Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania
| | - Kimberly Skelding
- Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania
| | - Armstrong Arthur
- Department of Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania
| | - Dipan Desai
- Department of Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania
| | - G. Craig Wood
- Geisinger Center for Research, Geisinger Medical Center, Danville, Pennsylvania
| | - James Blankenship
- Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania
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605
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Stettler C, Allemann S, Wandel S, Kastrati A, Morice MC, Schömig A, Pfisterer ME, Stone GW, Leon MB, de Lezo JS, Goy JJ, Park SJ, Sabaté M, Suttorp MJ, Kelbaek H, Spaulding C, Menichelli M, Vermeersch P, Dirksen MT, Cervinka P, De Carlo M, Erglis A, Chechi T, Ortolani P, Schalij MJ, Diem P, Meier B, Windecker S, Jüni P. Drug eluting and bare metal stents in people with and without diabetes: collaborative network meta-analysis. BMJ 2008; 337:a1331. [PMID: 18757996 PMCID: PMC2527175 DOI: 10.1136/bmj.a1331] [Citation(s) in RCA: 218] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To compare the effectiveness and safety of three types of stents (sirolimus eluting, paclitaxel eluting, and bare metal) in people with and without diabetes mellitus. DESIGN Collaborative network meta-analysis. DATA SOURCES Electronic databases (Medline, Embase, the Cochrane Central Register of Controlled Trials), relevant websites, reference lists, conference abstracts, reviews, book chapters, and proceedings of advisory panels for the US Food and Drug Administration. Manufacturers and trialists provided additional data. REVIEW METHODS Network meta-analysis with a mixed treatment comparison method to combine direct within trial comparisons between stents with indirect evidence from other trials while maintaining randomisation. Overall mortality was the primary safety end point, target lesion revascularisation the effectiveness end point. RESULTS 35 trials in 3852 people with diabetes and 10,947 people without diabetes contributed to the analyses. Inconsistency of the network was substantial for overall mortality in people with diabetes and seemed to be related to the duration of dual antiplatelet therapy (P value for interaction 0.02). Restricting the analysis to trials with a duration of dual antiplatelet therapy of six months or more, inconsistency was reduced considerably and hazard ratios for overall mortality were near one for all comparisons in people with diabetes: sirolimus eluting stents compared with bare metal stents 0.88 (95% credibility interval 0.55 to 1.30), paclitaxel eluting stents compared with bare metal stents 0.91 (0.60 to 1.38), and sirolimus eluting stents compared with paclitaxel eluting stents 0.95 (0.63 to 1.43). In people without diabetes, hazard ratios were unaffected by the restriction. Both drug eluting stents were associated with a decrease in revascularisation rates compared with bare metal stents in people both with and without diabetes. CONCLUSION In trials that specified a duration of dual antiplatelet therapy of six months or more after stent implantation, drug eluting stents seemed safe and effective in people both with and without diabetes.
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Affiliation(s)
- Christoph Stettler
- Institute of Social and Preventive Medicine, University of Bern, 3012 Bern, Switzerland
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606
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Becker RC, Meade TW, Berger PB, Ezekowitz M, O'Connor CM, Vorchheimer DA, Guyatt GH, Mark DB, Harrington RA. The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:776S-814S. [PMID: 18574278 DOI: 10.1378/chest.08-0685] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The following chapter devoted to antithrombotic therapy for chronic coronary artery disease (CAD) is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading see the "Grades of Recommendation" chapter by Guyatt et al in this supplement, CHEST 2008; 133[suppl]:123S-131S). Among the key recommendations in this chapter are the following: for patients with non-ST-segment elevation (NSTE)-acute coronary syndrome (ACS) we recommend daily oral aspirin (75-100 mg) [Grade 1A]. For patients with an aspirin allergy, we recommend clopidogrel, 75 mg/d (Grade 1A). For patients who have received clopidogrel and are scheduled for coronary bypass surgery, we suggest discontinuing clopidogrel for 5 days prior to the scheduled surgery (Grade 2A). For patients after myocardial infarction, after ACS, and those with stable CAD and patients after percutaneous coronary intervention (PCI), we recommend daily aspirin (75-100 mg) as indefinite therapy (Grade 1A). We recommend clopidogrel in combination with aspirin for patients experiencing ST-segment elevation (STE) and NSTE-ACS (Grade 1A). For patients with contraindications to aspirin, we recommend clopidogrel as monotherapy (Grade 1A). For long-term treatment after PCI in patients who receive antithrombotic agents such as clopidogrel or warfarin, we recommend aspirin (75 to 100 mg/d) [Grade 1B]. For patients who undergo bare metal stent placement, we recommend the combination of aspirin and clopidogrel for at least 4 weeks (Grade 1A). We recommend that patients receiving drug-eluting stents (DES) receive aspirin (325 mg/d for 3 months followed by 75-100 mg/d) and clopidogrel 75 mg/d for a minimum of 12 months (Grade 2B). For primary prevention in patients with moderate risk for a coronary event, we recommend aspirin, 75-100 mg/d, over either no antithrombotic therapy or vitamin K antagonist (Grade 1A).
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Affiliation(s)
- Richard C Becker
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
| | - Thomas W Meade
- Non Comm Disease Epidemiology, London School of Hygiene Tropical, London, UK
| | | | | | | | | | - Gordon H Guyatt
- McMaster University Health Sciences Centre, Hamilton, ON, Canada
| | | | - Robert A Harrington
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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607
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Daemen J, Boersma E, Flather M, Booth J, Stables R, Rodriguez A, Rodriguez-Granillo G, Hueb WA, Lemos PA, Serruys PW. Long-term safety and efficacy of percutaneous coronary intervention with stenting and coronary artery bypass surgery for multivessel coronary artery disease: a meta-analysis with 5-year patient-level data from the ARTS, ERACI-II, MASS-II, and SoS trials. Circulation 2008; 118:1146-54. [PMID: 18725490 DOI: 10.1161/circulationaha.107.752147] [Citation(s) in RCA: 231] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Randomized trials that studied clinical outcomes after percutaneous coronary intervention (PCI) with bare metal stenting versus coronary artery bypass grafting (CABG) are underpowered to properly assess safety end points like death, stroke, and myocardial infarction. Pooling data from randomized controlled trials increases the statistical power and allows better assessment of the treatment effect in high-risk subgroups. METHODS AND RESULTS We performed a pooled analysis of 3051 patients in 4 randomized trials evaluating the relative safety and efficacy of PCI with stenting and CABG at 5 years for the treatment of multivessel coronary artery disease. The primary end point was the composite end point of death, stroke, or myocardial infarction. The secondary end point was the occurrence of major adverse cardiac and cerebrovascular accidents, death, stroke, myocardial infarction, and repeat revascularization. We tested for heterogeneities in treatment effect in patient subgroups. At 5 years, the cumulative incidence of death, myocardial infarction, and stroke was similar in patients randomized to PCI with stenting versus CABG (16.7% versus 16.9%, respectively; hazard ratio, 1.04, 95% confidence interval, 0.86 to 1.27; P=0.69). Repeat revascularization, however, occurred significantly more frequently after PCI than CABG (29.0% versus 7.9%, respectively; hazard ratio, 0.23; 95% confidence interval, 0.18 to 0.29; P<0.001). Major adverse cardiac and cerebrovascular events were significantly higher in the PCI than the CABG group (39.2% versus 23.0%, respectively; hazard ratio, 0.53; 95% confidence interval, 0.45 to 0.61; P<0.001). No heterogeneity of treatment effect was found in the subgroups, including diabetic patients and those presenting with 3-vessel disease. CONCLUSIONS In this pooled analysis of 4 randomized trials, PCI with stenting was associated with a long-term safety profile similar to that of CABG. However, as a result of persistently lower repeat revascularization rates in the CABG patients, overall major adverse cardiac and cerebrovascular event rates were significantly lower in the CABG group at 5 years.
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Affiliation(s)
- Joost Daemen
- Thoraxcenter, Ba-583, Dr Molewaterplein 40, 3015 GD Rotterdam, Netherlands
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608
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Newsome LT, Kutcher MA, Royster RL. Coronary artery stents: Part I. Evolution of percutaneous coronary intervention. Anesth Analg 2008; 107:552-69. [PMID: 18633035 DOI: 10.1213/ane.0b013e3181732049] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The subspecialty of interventional cardiology has made significant progress in the management of coronary artery disease over the past three decades with the development of percutaneous coronary transluminal angioplasty, atherectomy, and bare-metal and drug-eluting stents (DES). Bare-metal stents (BMS) maintain vessel lumen diameter by acting as a scaffold and prevent collapse incurred by angioplasty. However, these devices cause neointimal hyperplasia leading to in-stent restenosis and requiring reintervention in more than 20% of patients by 6 mo. DES (sirolimus and paclitaxel) prevent restenosis by inhibiting neointimal hyperplasia. However, DESs also delay endothelialization, causing the stents to remain thrombogenic for an extended, yet unknown, period of time. Late stent thrombosis is associated with a 45% mortality rate. Premature discontinuation of antiplatelet therapy, particularly clopidogrel, is the strongest predictor of stent thrombosis. Sixty percent of patients receive stents for off-label (unapproved) indications, which also increases the frequency of stent thrombosis. Clopidogrel and aspirin are the cornerstone of therapy in the prevention of stent thrombosis in both BMS and DES. Recommendations pertaining to the optimal duration of dual-antiplatelet therapy have been debated. Both the Food and Drug Administration and the American Heart Association/American College of Cardiologists, in association with other major societies, have made recommendations to extend the duration of dual-antiplatelet therapy in patients with DES to 1 yr. The 6-wk duration of dual-antiplatelet therapy in patients with BMS remains unchanged. All patients with coronary stents must remain on life-long aspirin monotherapy. Since the introduction of percutaneous transluminal coronary angioplasty for the treatment of coronary atherosclerosis, the practice of percutaneous coronary intervention has undergone a dramatic transformation from simple balloon dilation catheters to sophisticated mechanical endoprostheses. These advancements have impacted the practice of perioperative medicine. In this series of two articles, in Part I we will review the evolution of percutaneous coronary intervention and discuss the issues associated with percutaneous transluminal coronary angioplasty and coronary stenting; in Part II we will discuss perioperative issues and management strategies of coronary stents during noncardiac surgery.
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Affiliation(s)
- Lisa T Newsome
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1009, USA.
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609
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Barthwal R, Herman BA. Very late stent thrombosis after discontinuation of clopidogrel therapy. Med J Aust 2008; 189:229-30. [DOI: 10.5694/j.1326-5377.2008.tb01992.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Accepted: 06/11/2008] [Indexed: 01/23/2023]
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610
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From randomized trials to registry studies: translating data into clinical information. ACTA ACUST UNITED AC 2008; 5:613-20. [PMID: 18679381 DOI: 10.1038/ncpcardio1307] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Accepted: 06/10/2008] [Indexed: 11/08/2022]
Abstract
All clinicians face the challenge of practicing evidence-based medicine and are confronted with data from a variety of studies, ranging from prospective randomized and registry studies to retrospective analyses. Unfortunately, the data frequently provide conflicting recommendations. How then should one interpret the information so that study findings can be applied directly in patient care? To evaluate the relevance of the abundance of studies published and how they apply to an individual patient, physicians must understand subtle nuances of study design and their effect on the interpretation of the results. In this Review, we examine the strengths and weaknesses of different study designs with the aim of providing the reader with a greater understanding how best to apply study results in the clinical setting.
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611
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Roy P, Bonello L, de Labriolle A, Okabe T, Pinto Slottow TL, Steinberg DH, Torguson R, Smith K, Xue Z, Satler LF, Kent KM, Suddath WO, Pichard AD, Waksman R. Two-year outcome of patients treated with sirolimus- versus paclitaxel-eluting stents in an unselected population with coronary artery disease (from the REWARDS Registry). Am J Cardiol 2008; 102:292-7. [PMID: 18638589 DOI: 10.1016/j.amjcard.2008.03.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Revised: 03/07/2008] [Accepted: 03/07/2008] [Indexed: 12/01/2022]
Abstract
Multiple studies comparing sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) in patients with coronary artery disease have been performed. Despite these comparisons, it remains uncertain whether a differential in long-term efficacy and safety exists. Unselected patients treated exclusively with 1 drug-eluting stent type were enrolled in the Registry Experience at the Washington Hospital Center with Drug-Eluting Stents. There were 2,099 patients (3,766 lesions) treated with SES and 1,079 patients (1,850 lesions) treated with PES. Patients were followed at 30 days, 1 year, and 2 years for the clinical endpoints of death, myocardial infarction, target vessel revascularization, and definite and definite/probable stent thrombosis. Patients in the SES group had more dyslipidemia, history of congestive heart failure, and ostial lesions; patients treated with PES had more previous coronary artery bypass surgery, unstable angina, and type C lesions. At 2 years, unadjusted major adverse cardiac events (MACE) (22.6% vs 21.1%, p = 0.3) and target vessel revascularization (13.3% vs 11.2%, p = 0.1) were comparable. The incidence of definite stent thrombosis was higher in the SES group (1.8% vs 0.9%, p = 0.05) driven by early events. Similar results were seen after adjustment for baseline differences: MACE (hazard ratio 1.1, 95% confidence interval [CI] 0.9 to 1.3, p = 0.5), definite stent thrombosis (hazard ratio 2.3, 95% CI 1.0 to 5.2, p = 0.05), and target vessel revascularization (hazard ratio 1.1, 95% CI 0.9 to 1.4, p = 0.4). The incidence and rate of late stent thrombosis (>30 days) were similar (0.7% vs 0.5%, p = 0.4 and 0.24%/year, both groups, respectively). In conclusion, no major differential in long-term safety or efficacy was detected between SES and PES; both stent types were efficacious in reducing revascularization but were limited by a small continual increase in late stent thrombosis.
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Affiliation(s)
- Probal Roy
- Division of Cardiology, Washington Hospital Center, Washington, DC, USA
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612
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Austin D, Oldroyd KG, McConnachie A, Slack R, Eteiba H, Flapan AD, Jennings KP, Northcote RJ, Pell AC, Starkey IR, Pell JP. Drug-Eluting Stents Versus Bare-Metal Stents for Off-Label Indications. Circ Cardiovasc Interv 2008; 1:45-52. [DOI: 10.1161/circinterventions.108.769042] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background—
The US Food and Drug Administration recently concluded that data on off-label drug-eluting stent (DES) safety are limited. However, in actual clinical practice, DES are often used for off-label indications, and observational studies demonstrate that complications are higher when compared with on-label use. We aimed to determine whether clinical outcomes differ after DES and bare-metal stent implantation in a patient cohort defined by DES off-label indications.
Methods and Results—
We used the national revascularization registry in Scotland to identify patients who underwent coronary stenting for an off-label indication between January 2003 and September 2005. Individual-level linkage to comprehensive national admission and death databases was used to ascertain the end points of death, myocardial infarction, and target-vessel revascularization. We calculated propensity scores on the basis of clinical, demographic, and angiographic variables and matched DES to bare-metal stents on a 1:1 basis. The final study population consisted of 1642 patients, well matched for important covariables at baseline. Event-free survival was calculated over 24 months with the Kaplan-Meier method. All-cause death was more common after bare-metal stent implantation during follow-up (7.7% versus 6.6%; hazard ratio 0.63; 95% confidence interval, 0.40 to 0.99;
P
=0.04). No difference in the rates of myocardial infarction were noted (7.3% versus 7.5%; hazard ratio 1.02; 95% confidence interval, 0.69 to 1.54;
P
=0.92). Target-vessel revascularization was reduced in patients treated with DES (13.9% versus 10.7%; hazard ratio 0.67; 95% confidence interval, 0.49 to 0.93;
P
=0.02).
Conclusions—
At 24 months, patients treated with DES for off-label indications had lower rates of death and target-vessel revascularization and similar rates of myocardial infarction, as compared with patients treated with bare-metal stents.
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Affiliation(s)
- David Austin
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
| | - Keith G. Oldroyd
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
| | - Alex McConnachie
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
| | - Rachel Slack
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
| | - Hany Eteiba
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
| | - Andrew D. Flapan
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
| | - Kevin P. Jennings
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
| | - Robin J. Northcote
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
| | - Alastair C.H. Pell
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
| | - Ian R. Starkey
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
| | - Jill P. Pell
- From the Section of Public Health and Health Policy (D.A., R.S., J.P.P.) and Robertson Centre for Biostatistics (A.M.), University of Glasgow; Western Infirmary (K.G.O.); Glasgow Royal Infirmary (H.E.); Victoria Infirmary (R.J.N.), Glasgow; Edinburgh Royal Infirmary (A.D.F.); Western General Hospital (I.R.S.), Edinburgh; Aberdeen Royal Infirmary (K.P.J.), Aberdeen; and Monklands Hospital (A.C.H.P.), Airdrie, Lanarkshire, United Kingdom
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613
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Pfisterer M, Brunner-La Rocca HP, Rickenbacher P, Hunziker P, Mueller C, Nietlispach F, Leibundgut G, Bader F, Kaiser C. Long-term benefit-risk balance of drug-eluting vs. bare-metal stents in daily practice: does stent diameter matter? Three-year follow-up of BASKET. Eur Heart J 2008; 30:16-24. [PMID: 19033260 DOI: 10.1093/eurheartj/ehn516] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Matthias Pfisterer
- Department of Cardiology, University Hospital Basel, Petersgraben, Basel, Switzerland.
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614
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Comparison of stent thrombosis, myocardial infarction, and mortality following drug-eluting versus bare-metal stent coronary intervention in patients with diabetes mellitus. Am J Cardiol 2008; 102:165-72. [PMID: 18602515 DOI: 10.1016/j.amjcard.2008.03.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Revised: 03/04/2008] [Accepted: 03/04/2008] [Indexed: 01/06/2023]
Abstract
The aim of this study was to examine outcomes subsequent to implantation of drug-eluting stents (DESs) and bare-metal stents (BMSs) in patients with diabetes. From January 2002 to June 2005, data from all percutaneous coronary interventions performed in Western Denmark were prospectively recorded. A total of 1,423 consecutive diabetic patients treated with stent implantation (2,094 lesions) were followed up for 15 months. Of these, 871 patients (1,180 lesions) were treated with a BMS, and 552 patients (914 lesions) were treated with a DES. Dual antiplatelet therapy was recommended for 12 months in both treatment groups. Data for death and myocardial infarction (MI) were ascertained from national health care databases. Use of DESs was not associated with increased risk of definite stent thrombosis (adjusted relative risk [RR] 0.76, 95% confidence interval [CI] 0.10 to 3.26) or MI (adjusted RR 0.90, 95% CI 0.53 to 1.52). In the DES group compared with the BMS group, adjusted RRs of target-lesion revascularization (adjusted RR 0.48, 95% CI 0.33 to 0.71), total mortality (adjusted RR 0.66, 95% CI 0.44 to 0.99), and cardiac mortality (adjusted RR 0.53, 95% CI 0.31 to 0.90) decreased by 52%, 34%, and 47%, respectively. In conclusion, use of DESs reduced target-lesion revascularization in diabetic patients receiving routine clinical care. This result was obtained without increased risk of death, stent thrombosis, or MI.
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615
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Austin D, Pell JP, Oldroyd KG. Drug-eluting stents: a review of current evidence on clinical effectiveness and late complications. Scott Med J 2008; 53:16-24. [PMID: 18422205 DOI: 10.1258/rsmsmj.53.1.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Drug-eluting stent (DES) use has increased greatly as a result of early trial evidence of a reduction in restenosis. However, thet are expensive and do not improve patient survival. Therefore their use has been rationed in some countries. There is a paucity of clinical evidence for some patient groups such as non-ST elevation myocardial infarction and multi-vessel disease. Recent studies suggest that the early benefits of drug-eluting stents may be offset by an increased risk in late stent thrombosis which is a potentially fatal complication. However, the absolute risk appears low and, as yet, there is no evidence of an increased risk of stent-thrombosis related myocardial infarction or death in patients studied in randomised clinical trials. Long-term use of anti-platelet therapy may protect against the risk of late stent thrombosis but the optimal treatment strategy is currently unclear. The aim of this paper is to provide an up-to-date review of the current evidence on DES; including clinical effectiveness, the limitations of existing trials, the emerging evidence on late stent thrombosis and the potential role of clopidogrel.
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Affiliation(s)
- D Austin
- Department of Public Health and Health Policy, University of Glasgow, Glasgow, UK
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616
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Chieffo A, Park SJ, Meliga E, Sheiban I, Lee MS, Latib A, Kim YH, Valgimigli M, Sillano D, Magni V, Biondi-Zoccai G, Montorfano M, Airoldi F, Rogacka R, Carlino M, Michev I, Lee CW, Hong MK, Park SW, Moretti C, Bonizzoni E, Sangiorgi GM, Tobis J, Serruys PW, Colombo A. Late and very late stent thrombosis following drug-eluting stent implantation in unprotected left main coronary artery: a multicentre registry. Eur Heart J 2008; 29:2108-15. [PMID: 18565967 DOI: 10.1093/eurheartj/ehn270] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Alaide Chieffo
- San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
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617
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Booth J, Clayton T, Pepper J, Nugara F, Flather M, Sigwart U, Stables RH. Randomized, controlled trial of coronary artery bypass surgery versus percutaneous coronary intervention in patients with multivessel coronary artery disease: six-year follow-up from the Stent or Surgery Trial (SoS). Circulation 2008; 118:381-8. [PMID: 18606919 DOI: 10.1161/circulationaha.107.739144] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Stent or Surgery Trial is a randomized, controlled trial comparing percutaneous coronary intervention with coronary artery bypass grafting (CABG) for patients with multivessel disease. Initial results at a median follow-up of 2 years showed a survival advantage for patients randomized to CABG. This article reports survival outcome at a median follow-up of 6 years. METHODS AND RESULTS A total of 988 (n=488 percutaneous coronary intervention, n=500 CABG) patients were randomized at 53 centers during the period from 1996 to 1999. Investigators established survival status from hospital or community medical records or national databases or by direct contact with patients and their relatives. All-cause mortality was compared with hazard ratios and confidence intervals calculated from Cox proportional hazards models. Prespecified subgroup analyses for diabetes mellitus, angina grade, and angiographic severity of coronary disease at baseline were performed with tests for interaction. At a median follow-up of 6 years, 53 patients (10.9%) died in the percutaneous coronary intervention group compared with 34 (6.8%) in the CABG group (hazard ratio 1.66, 95% confidence interval 1.08 to 2.55, P=0.022). Little evidence was found that the treatment effect on mortality differed between subgroups according to baseline angina grade (interaction test P=0.52), the severity of coronary disease (P=0.92), or diabetic status (P=0.15). CONCLUSIONS At a median follow-up of 6 years, a continuing survival advantage was observed for patients managed with CABG, which is not consistent with results from other stent-versus-CABG studies.
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Affiliation(s)
- Jean Booth
- Clinical Trials and Evaluation Unit, Royal Brompton Hospital, London, United Kingdom
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618
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Holmes DR, Firth BG, Hodgson PK, Rihal CS, Wood DL, Cohen DJ. Evolving challenges in medical device evaluation. Catheter Cardiovasc Interv 2008; 72:1-6. [PMID: 18546235 DOI: 10.1002/ccd.21541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- David R Holmes
- Internal Medicine and Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA.
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619
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Association between C-reactive protein and angiographic restenosis after bare metal stents: an updated and comprehensive meta-analysis of 2747 patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2008; 9:156-65. [DOI: 10.1016/j.carrev.2008.01.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Revised: 01/04/2008] [Accepted: 01/18/2008] [Indexed: 11/23/2022]
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620
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Coylewright M, Blumenthal RS, Post W. Placing COURAGE in context: review of the recent literature on managing stable coronary artery disease. Mayo Clin Proc 2008; 83:799-805. [PMID: 18613996 DOI: 10.4065/83.7.799] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Coronary artery disease (CAD) is the leading cause of death in the United States, but prevention and intervention efforts are lowering mortality. This progress is being undercut by rising rates of obesity and diabetes, and adherence to evidence-based prevention efforts is less than ideal. Many patients with CAD who are asymptomatic or have minimal symptoms undergo percutaneous coronary intervention (PCI) each year, even though PCI has not been demonstrated to improve survival for this group. Motivated by the recent controversy surrounding the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, we reviewed randomized clinical trials with follow-up published in the past decade comparing medical management with revascularization for stable CAD to provide a context for the COURAGE trial. We searched for relevant studies published from January 1, 1997, until the date of electronic publication of the COURAGE study results, March 26, 2007; references cited in the COURAGE publication were also reviewed. Evidence shows that PCI does not decrease mortality or risk of myocardial infarction over optimal medical or lifestyle therapy in patients with chronic stable CAD. In published studies, early benefits in angina control afforded by revascularization wane over time; this could change with modern interventional therapies. The final word is not that medical therapy is superior for all patients, but that optimizing medical and lifestyle therapy is appropriate as an initial management strategy for most patients who do not have unstable or disabling symptoms. It is essential that systems are set in place to make the medical management of patients with CAD second nature; this focus could be one of the most powerful results of the COURAGE trial.
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Affiliation(s)
- Megan Coylewright
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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621
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Safety and effectiveness of drug-eluting stents among diabetic patients: a propensity analysis. Am Heart J 2008; 156:125-34. [PMID: 18585507 DOI: 10.1016/j.ahj.2008.01.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 01/30/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Diabetic patients frequently receive drug-eluting stents (DES) during percutaneous coronary interventions (PCI), but recent data have raised concerns as to whether DES are associated with increased risk of myocardial infarction or death. Accordingly, we sought to evaluate the long-term safety and effectiveness of DES in diabetic patients. METHODS We used a propensity score matching method to create and analyze a well-balanced cohort that included 2,374 diabetic patients who received PCI in Ontario, Canada, from December 1, 2003, to March 31, 2005. Primary outcomes of interest were repeat target-vessel revascularization, myocardial infarction, and death after the index PCI. RESULTS The mean age of our diabetic cohort was 64 years, and 68% of the patents were male. At 2 years, rates of repeat target-vessel revascularization were significantly lower among diabetic patients treated with DES compared with those treated with bare metal stents (BMS) (7.1% vs 14.4%, P < .001). Myocardial infarction rates were not significantly different between the 2 groups after 2 years (6.6% in DES group vs 4.5% in BMS group, P = .45). In addition, mortality was not statistically different among diabetic patients treated with DES (7.6%) and BMS (9.5%) (P = .086). CONCLUSIONS Drug-eluting stents are effective among diabetic patients in substantially reducing the need for repeat target-vessel revascularization. The overall rates of myocardial infarction were not significantly different between DES and BMS. In addition, the mortality of diabetic patients who received DES was not significantly increased compared with BMS.
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622
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Mishkel GJ, Moore AL, Markwell S, Shelton ME. Correlates of late and very late thrombosis of drug eluting stents. Am Heart J 2008; 156:141-7. [PMID: 18585509 DOI: 10.1016/j.ahj.2008.02.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Accepted: 02/18/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND Late and very late thrombosis of coronary drug-eluting stents (DES) has received much attention but essentially remains unpredictable. We sought to identify correlates of stent thrombosis (ST) developing >30 days after DES implantation. METHODS We analyzed data from our single-center registry on 5,342 consecutive patients, who underwent a first DES implant between May 2003 and December 2006. The Academic Research Consortium definitions were applied to classify definite, probable, and possible ST. Cox regression analysis was performed to identify predictors of ST. RESULTS Follow-up information was obtained at 6 months and at 1, 2, and 3 years after DES implantation in 97.2%, 95.2%, 92.4%, and 89.8% of patients, respectively. We identified 34 patients who developed definite and 5 with probable ST >30 days after the index stent procedure. The 3-year cumulative incidence of definite and definite + probable ST >30 days was 1.33% and 1.50%, respectively. By Cox multiple variable regression, predictors of definite + probable ST were age (hazard ratio [HR] 0.95, 95% CI 0.92-0.98, P < .001), current smoking (HR 2.55, 95% CI 1.29-5.07, P = .007), prior percutaneous coronary intervention (HR 2.68, 95% CI 1.42-5.05, P = .002), "off-label" DES indication (HR 3.10, 95% CI 1.10-8.75, P = .032), bifurcation stenting (HR 2.37, 95% CI 1.40-3.99, P = .001), and stenting an occluded vessel (HR 3.02, 95% CI 1.59-5.74, P < .001). CONCLUSIONS We identified several baseline characteristics, which, when combined, may identify patients at risk for late-occurring ST, particularly after off-label DES placement.
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Affiliation(s)
- Gregory J Mishkel
- Prairie Heart Institute at St John's Hospital, Springfield, IL 62794-9420, USA.
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623
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Groeneveld PW, Matta MA, Greenhut AP, Yang F. Drug-eluting compared with bare-metal coronary stents among elderly patients. J Am Coll Cardiol 2008; 51:2017-24. [PMID: 18498954 DOI: 10.1016/j.jacc.2008.01.057] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Revised: 01/04/2008] [Accepted: 01/08/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVES We sought to determine whether drug-eluting stents (DES) were associated with improved clinical outcomes compared with bare-metal stents (BMS) among a nationally representative, nonexperimental elderly patient cohort. BACKGROUND Randomized controlled clinical trials comparing DES and BMS for treatment of coronary artery disease indicate that although the use of DES reduces rates of coronary restenosis after percutaneous coronary intervention, it does not reduce the rates of mortality or acute myocardial infarction (AMI). Nevertheless, clinical outcomes of DES in nonexperimental, routine clinical practice are uncertain. METHODS We assembled a retrospective cohort of elderly Medicare beneficiaries (n = 76,525) who received DES within 9 months after Food and Drug Administration approval of the sirolimus-eluting stent (April 2003 to December 2003). Using propensity score methods, we assembled 2 matched control cohorts who received BMS from July 2002 to March 2003 (historical controls) or from April 2003 to December 2003 (contemporary controls). Patient enrollment and claims records were obtained through December 2005 to ascertain mortality, hospitalization for AMI, and subsequent coronary revascularization. RESULTS Receipt of a DES was associated with a significant survival benefit, with an adjusted mortality hazard ratio of 0.83 (95% confidence interval 0.81 to 0.86) compared with contemporary controls, and a hazard ratio of 0.79 (95% confidence interval 0.77 to 0.81) compared with historical controls (control group heterogeneity: p < 0.001). Patients with DES had significantly lower adjusted rates of revascularization procedures within the first 2 years after PCI and lower hospitalization rates for subsequent AMI. CONCLUSIONS In contrast to clinical trial results, DES receipt was associated with fewer subsequent revascularization procedures, lower rates of hospitalization for AMI, and improved survival among elderly Medicare beneficiaries.
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Affiliation(s)
- Peter W Groeneveld
- Department of Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Pittsburgh Veterans Affairs Health Care System, Philadelphia, Pennsylvania Pennsylvania 19104-4155, USA.
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624
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Malenka DJ, Kaplan AV, Lucas FL, Sharp SM, Skinner JS. Outcomes following coronary stenting in the era of bare-metal vs the era of drug-eluting stents. JAMA 2008; 299:2868-76. [PMID: 18577731 PMCID: PMC3322376 DOI: 10.1001/jama.299.24.2868] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
CONTEXT Although drug-eluting stents reduce restenosis rates relative to bare-metal stents, concerns have been raised that drug-eluting stents may also be associated with an increased risk of stent thrombosis. Our study focused on the effect of stent type on population-based interventional outcomes. OBJECTIVE To compare outcomes of Medicare beneficiaries who underwent nonemergent coronary stenting before and after the availability of drug-eluting stents. DESIGN, SETTING, AND PATIENTS Observational study of 38,917 Medicare patients who underwent nonemergent coronary stenting from October 2002 through March 2003 when only bare-metal stents were available (bare-metal stent era cohort) and 28,086 similar patients who underwent coronary stenting from September through December 2003, when 61.5% of patients received a drug-eluting stent and 38.5% received a bare-metal stent (drug-eluting stent era cohort). Follow-up data were available through December 31, 2005. MAIN OUTCOME MEASURES Coronary revascularization (percutaneous coronary intervention, coronary artery bypass surgery), ST-elevation myocardial infarction, survival through 2 years of follow-up. RESULTS Relative to the bare-metal stent era, patients treated in the drug-eluting stent era had lower 2-year risks for repeat percutaneous coronary interventions (17.1% vs 20.0%, P < .001) and coronary artery bypass surgery (2.7% vs 4.2%, P < .01). The difference in need for repeat revascularization procedures between these 2 eras remained significant after risk adjustment (hazard ratio, 0.82; 95% confidence interval, 0.79-0.85). There was no difference in unadjusted mortality risks at 2 years (8.4% vs 8.4%, P =.98 ), but a small decrease in ST-elevation myocardial infarction existed (2.4% vs 2.0%, P < .001). The adjusted hazard of death or ST-elevation myocardial infarction at 2 years was similar (hazard ratio, 0.96; 95% confidence interval, 0.92-1.01). CONCLUSION The widespread adoption of drug-eluting stents into routine practice was associated with a decline in the need for repeat revascularization procedures and had similar 2-year risks for death or ST-elevation myocardial infarction to bare-metal stents.
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Affiliation(s)
- David J Malenka
- Section of Cardiology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
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625
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Bavry AA, Bhatt DL. Appropriate use of drug-eluting stents: balancing the reduction in restenosis with the concern of late thrombosis. Lancet 2008; 371:2134-43. [PMID: 18572082 DOI: 10.1016/s0140-6736(08)60922-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Restenosis is a serious occurrence that can lead not only to recurrent angina and repeat revascularisation but also to acute coronary syndromes. Drug-eluting stents revolutionised interventional cardiology owing to their pronounced ability to reduce restenosis compared with bare-metal stents. Attention has now shifted to safety of these devices because of evidence suggesting an association with late stent thrombosis. Findings of randomised clinical trials have not shown that drug-eluting stents result in excess mortality after 4-5 years of follow-up. Current recommendations are that individuals with a drug-eluting stent should receive at least 12 months of uninterrupted dual antiplatelet treatment; patients must understand the importance of this long-term regimen. Patients' assessment should focus on bleeding abnormalities, pre-existing disorders that need anticoagulation treatment, and possible future surgical procedures, since these factors could all contraindicate use of drug-eluting stents. Many people will do well with a bare-metal stent, whereas for individuals with a high likelihood of restenosis and late thrombosis, medical management or surgical revascularisation might be preferred options.
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Affiliation(s)
- Anthony A Bavry
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
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626
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The year in interventional cardiology. J Am Coll Cardiol 2008; 51:2355-69. [PMID: 18549922 DOI: 10.1016/j.jacc.2008.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 03/17/2008] [Accepted: 03/18/2008] [Indexed: 11/22/2022]
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627
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A Systemic Combination Therapy with Granulocyte-Colony Stimulating Factor Plus Erythropoietin Aggravates the Healing Process of Balloon-Injured Rat Carotid Arteries. Cardiovasc Drugs Ther 2008; 22:351-62. [PMID: 18528750 DOI: 10.1007/s10557-008-6117-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Accepted: 05/08/2008] [Indexed: 10/22/2022]
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628
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Scheller B, Hehrlein C, Bocksch W, Rutsch W, Haghi D, Dietz U, Böhm M, Speck U. Two year follow-up after treatment of coronary in-stent restenosis with a paclitaxel-coated balloon catheter. Clin Res Cardiol 2008; 97:773-81. [PMID: 18536865 DOI: 10.1007/s00392-008-0682-5] [Citation(s) in RCA: 198] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Accepted: 05/16/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND We are presenting an extension of a previously published trial on the efficacy and safety of a paclitaxel-coated balloon in coronary ISR in a larger patient population and after a complete follow-up of 2 years. METHODS Hundred eight patients were enrolled in two separately randomized, double-blind multicenter trials on efficacy and safety using an identical protocol. Patients were treated by the paclitaxel-coated (3 microg/mm(2) balloon surface; Paccocath) or an uncoated balloon. The main inclusion criteria were a diameter stenosis of >or=70% and <30 mm length with a vessel diameter of 2.5-3.5 mm. The primary endpoint was angiographic late lumen loss in-segment. Secondary endpoints included binary restenosis rate and major adverse cardiovascular events (MACE). RESULTS Quantitative coronary angiography revealed no differences in baseline parameters. After six months in-segment late lumen loss was 0.81 +/- 0.79 mm in the uncoated balloon group vs. 0.11 +/- 0.45 mm (P < 0.001) in the drug-coated balloon group resulting in a binary restenosis rate of 25/49 vs. 3/47 (P < 0.001). Until 12 months post procedure 20 patients in the uncoated balloon group compared to two patients in the coated balloon group required target lesion revascularization (P = 0.001). Between 12 and 24 only two MACE were recorded, a stroke in the uncoated and a target lesion revascularization in the coated balloon group. CONCLUSION Treatment of coronary ISR with paclitaxel-coated balloon catheters persistently reduces repeat restenosis up to 2 years. (ClinicalTrials.gov Identifier: NCT00106587, NCT00409981).
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Affiliation(s)
- Bruno Scheller
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg, Saar, Germany.
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629
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Yau L, Molnar P, Moon MC, Buhay S, Werner JP, Molnar K, Saward L, Del Rizzo D, Zahradka P. Meta-iodobenzylguanidine, an inhibitor of arginine-dependent mono(ADP-ribosyl)ation, prevents neointimal hyperplasia. J Pharmacol Exp Ther 2008; 326:717-24. [PMID: 18523160 DOI: 10.1124/jpet.108.137513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The association of ADP-ribosylation with cell proliferation and ischemia-reperfusion injury suggests that it may be a suitable target for therapeutic control of revascularization-induced injury. The purpose of this study was to investigate the inhibitory actions of ADP-ribosylation inhibitors on restenosis. In organ culture, the poly(ADP-ribose) polymerase (PARP) inhibitor 3,4-dihydro-5-methylisoquinolinone (PD128763) was unable to prevent neointimal hyperplasia, whereas the arginine-dependent mono(ADP-ribosyl)transferase (ART) inhibitor meta-iodobenzylguanidine (MIBG) was highly effective (EC(50) 21 microM). Treatment with 3-aminobenzamide (3AB), a less potent ART inhibitor, also produced a significant reduction in neointimal hyperplasia. Single doses (25 mM) of MIBG and 3AB were also applied within a fibrin coagulum directly to the adventitial surface of the porcine femoral artery after balloon catheter injury in vivo. MIBG reduced the neointimal index, measured 14 days after angioplasty, by 82%, whereas 3AB was ineffective. However, when extended to 45 days, the neointimal index was not significantly decreased by MIBG treatment relative to control. Assessment of MIBG release from the fibrin glue showed that the bulk of the compound was eluted within 3 days, suggesting that the vehicle was not suitable for long-term delivery. On the other hand, direct infusion of MIBG into vessels was able to reduce neointimal hyperplasia over 14 days in organ culture. These data support the conclusion that the cellular retention characteristics of MIBG contribute significantly to the efficacy of this compound. Based on these results, ART, but not PARP, may be a credible target for therapeutic treatment of restenosis.
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Affiliation(s)
- Lorraine Yau
- University of Manitoba and St. Boniface General Hospital Research Centre, Winnipeg, Manitoba, Canada R2H 2A6
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630
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Biondi-Zoccai GGL, Lotrionte M, Anselmino M, Moretti C, Agostoni P, Testa L, Abbate A, Cosgrave J, Laudito A, Trevi GP, Sheiban I. Systematic review and meta-analysis of randomized clinical trials appraising the impact of cilostazol after percutaneous coronary intervention. Am Heart J 2008; 155:1081-9. [PMID: 18513523 DOI: 10.1016/j.ahj.2007.12.024] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Accepted: 12/26/2007] [Indexed: 02/05/2023]
Abstract
BACKGROUND Drug-eluting stents reduce the risk of restenosis after percutaneous coronary intervention (PCI) but may pose a risk of thrombosis. Cilostazol, an oral antiplatelet agent with pleiotropic effects including inhibition of neointimal hyperplasia, could hold the promise of preventing both restenosis and thrombosis. We systematically reviewed randomized clinical trials (RCTs) on the angiographic and clinical impact of cilostazol after PCI. METHODS We searched RCT in BioMedCentral, CENTRAL, clinicaltrials.gov, EMBASE, and PubMed (November 2007). Coprimary end points were binary angiographic restenosis and repeat revascularization, abstracted and pooled by means of random-effect relative risks (RRs). Small study/publication bias was appraised with multiple methods. RESULTS A total of 23 RCTs were included (5428 patients), with median follow-up of 6 months. Pooled analysis showed that cilostazol was associated with statistically significant reductions in binary angiographic restenosis (RR = 0.60 [0.49-0.73], P < .001) and repeat revascularization (RR = 0.69 [0.55-0.86], P = .001). Cilostazol appeared also safe, with no significant increase in the risk of stent thrombosis (RR = 1.35 [0.71-2.57], P = .36) or bleeding (RR = 0.71 [0.43-1.16], P = .17). However, small study bias was evident for both binary restenosis (P < .001) and repeat revascularization (P < .001), suggesting that at least part of the apparent benefits of cilostazol could be due to this type of confounding effect. CONCLUSIONS Cilostazol appears effective and safe in reducing the risk of restenosis and repeat revascularization after PCI, but available evidence is limited by small study effects. Awaiting larger RCTs, this inexpensive treatment can be envisaged in selected patients in which drug-eluting stents are contraindicated or when there is a need for neointimal hyperplasia inhibition.
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631
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Lim SY, Kim KS, Joo SJ, Jeong MH. Very late stent thrombosis after drug-eluting stent implantation in a patient without aspirin and clopidogrel resistance. J Korean Med Sci 2008; 23:556-9. [PMID: 18583901 PMCID: PMC2526514 DOI: 10.3346/jkms.2008.23.3.556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Very late stent thrombosis (VLST) after implantation of drug-eluting stent is rare, but very fatal complication after percutaneous coronary intervention. We report a case of VLST of a sirolimus-eluting Cypher stent (Cordis, Johnson and Johnson) presenting as acute ST elevation myocardial infarction at 26 months after deployment with continued combined dual antiplatelet medication of aspirin and clopidogrel. The patient did not show anti-platelet resistance.
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Affiliation(s)
- Sang Yup Lim
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Ki Seok Kim
- Department of Internal Medicine, Cheju National University, Jeju, Korea
| | - Seung Jae Joo
- Department of Internal Medicine, Cheju National University, Jeju, Korea
| | - Myung Ho Jeong
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
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632
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Shishehbor MH, Amini R, Raymond RE, Bavry AA, Brener SJ, Kapadia SR, Whitlow PL, Ellis SG, Bhatt DL. Safety and efficacy of overlapping sirolimus-eluting versus paclitaxel-eluting stents. Am Heart J 2008; 155:1075-80. [PMID: 18513522 DOI: 10.1016/j.ahj.2008.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 01/22/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND The short-term and long-term safety and efficacy of paclitaxel versus sirolimus-overlapping drug-eluting stents (DES) is unknown. We sought to examine the clinical consequences of overlapping sirolimus versus paclitaxel DES. METHODS We reviewed catheterization reports from April 2003 to May 2005 for all patients who underwent percutaneous coronary revascularization with DES. All patients were followed-up for at least 1 year. Patients were included if they received only 2 single-type overlapping stent (eg, sirolimus-sirolimus) during the index procedure. The end points included early (inhospital and 30-day) and late composite of all-cause mortality, stent thrombosis, myocardial infarction, and target lesion revascularization. RESULTS A total of 282 individuals met our study criteria. Of these, 188 had sirolimus and 94 had paclitaxel-overlapping DES. There were 78 events for a median follow-up of 24 months for the composite end point. No statistically significant differences between overlapping sirolimus and paclitaxel DES were seen for inhospital, 30-day (16% vs 23%, respectively; P = .13), and long-term (25% vs 33%, respectively; P = .16) composite end points. In addition, in Kaplan-Meier and Cox proportional hazard analysis, no significant differences for the composite end point were noted. CONCLUSIONS In this analysis, there were no significant differences in safety or efficacy between the 2 types of overlapping DES. Trends toward more events with overlapping paclitaxel stents should be evaluated in an adequately powered randomized controlled trial.
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Affiliation(s)
- Mehdi H Shishehbor
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
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633
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Daemen J, Simoons ML, Wijns W, Bagust A, Bos G, Bowen JM, Braunwald E, Camenzind E, Chevalier B, DiMario C, Fajadet J, Gitt A, Guagliumi G, Hillege HL, James S, Juni P, Kastrati A, Kloth S, Kristensen SD, Krucoff M, Legrand V, Pfisterer M, Rothman M, Serruys PW, Silber S, Steg PG, Tariah I, Wallentin L, Windecker SW, Aimonetti A, Allocco D, Baczynska A, Bagust A, Berenger M, Bos G, Boam A, Bowen J, Braunwald E, Calle J, Camenzind E, Campo G, Carlier S, Chevalier B, Daemen J, de Schepper J, Di Bisceglie G, DiMario C, Dobbels H, Fajadet J, Farb A, Ghislain J, Gitt A, Guagliumi G, Hellbardt S, Hillege H, ten Hoedt R, Isaia C, James S, de Jong P, Juni P, Kastrati A, Klasen E, Kloth S, Kristensen S, Krucoff M, Legrand V, Lekehal M, LeNarz L, Ni Mhullain F, Nagai H, Patteet A, Paunovic D, Pfisterer M, Potgieter A, Purdy I, Raveau-Landon C, Rothman M, Serruys P, Silber S, Simoons M, Steg P, Tariah I, Ternstrom S, Van Wuytswinkel J, Waliszewski M, Wallentin L, Wijns W, Windecker S. Meeting Report: ESC Forum on Drug Eluting Stents European Heart House, Nice, 27-28 September 2007. Eur Heart J 2008; 30:152-61. [DOI: 10.1093/eurheartj/ehn510] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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634
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Kitoga M, Pasquet A, Preumont V, Kefer J, Hermans MP, Vanoverschelde JL, Buysschaert M. Coronary in-stent restenosis in diabetic patients after implantation of sirolimus or paclitaxel drug-eluting coronary stents. DIABETES & METABOLISM 2008; 34:62-7. [PMID: 18069029 DOI: 10.1016/j.diabet.2007.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Revised: 09/21/2007] [Accepted: 09/25/2007] [Indexed: 11/17/2022]
Abstract
It is now emerging that, in patients who are at high risk for cardiovascular complications and, in particular, those with diabetes, the occurrence of late restenosis and thrombosis after treatment of coronary artery disease with drug-eluting stents is higher than earlier reports have suggested. Therefore, the aim of this study was to assess the prevalence of in-stent restenosis in a cohort of consecutive patients with diabetes treated for coronary disease in 2005 with drug-eluting stents [either sirolimus (58%) or paclitaxel (42%)]. The duration of follow-up was 9.0+/-3.4 months [mean+/-1 standard deviation (S.D.)]. A total of 154 patients (type 2 diabetes: 91%) were included in the study (age: 66+/-10 years), and the total number of implanted stents was 184. Two subjects died from cardiac causes, while myocardial infarction and (un)stable angina were observed in 3 (2%) and 39 (25%) patients, respectively. In-stent restenosis, appraised by angiography, was observed in 17 individuals (11%) after a mean follow-up of five months. Mean HbA(1c) in patients with restenosis was 7.6+/-1.8%. There was no difference in the rate of restenosis with sirolimus-(n=8) compared with paclitaxel-(n=9) eluting stents. Male gender, oral therapy for diabetes and stent diameter were predictors of in-stent restenosis. In conclusion, even over a medium-term period, in-stent restenosis remains a potential risk for coronary diabetic patients treated with drug-eluting devices.
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Affiliation(s)
- M Kitoga
- Service d'endocrinologie et nutrition, université catholique de Louvain, cliniques universitaires Saint-Luc, 10, avenue Hippocrate, 1200 Bruxelles, Belgium
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635
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Wang FW, Uretsky BF, Freeman JL, Zhang D, Giordano SH, Goodwin JS. Survival advantage in Medicare patients receiving drug-eluting stents compared with bare metal stents: real or artefactual? Catheter Cardiovasc Interv 2008; 71:636-43. [PMID: 18360856 DOI: 10.1002/ccd.21417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Concerns have been raised regarding late mortality, particularly from late stent thrombosis, from drug-eluting stents (DES). Randomized clinical trials have shown that DES decrease restenosis but do not decrease mortality compared with bare metal stents (BMS). These studies utilized well-defined clinical and angiographic subsets. In the "real world" drug-eluting stents are used in a much broader crosssection of patients. We evaluated mortality in the first year after implantation of DES, specifically the sirolimus-eluting stent (SES), Cypher vs. BMS in "real world" older patients using the Medicare claims database. METHODS AND RESULTS Data for the years 2002 (n = 6,890; pre-DES) and 2003 (n = 7,566; first year of DES use) (May through December of each year) were analyzed. BMS and DES groups had similar baseline characteristics except for small but significant differences with BMS patients being somewhat older, having more males and African Americans, and a higher percentage of peripheral artery disease and heart failure while DES patients had a higher percentage of diabetics and patients with prior revascularization procedures. A significant improvement in mortality using both unadjusted and adjusted analyses was observed for DES (6.0% vs. 11.4%, P < 0.0001; hazard ratio 1.98, 95% CI 1.68-2.34). Controlling for comorbidity, extent of disease, and other characteristics by multivariable analysis or by propensity analysis had little impact on these results. On the other hand, there was no change in overall mortality in all stented patients in 2003 compared with all stented patients in 2002. CONCLUSION An observed mortality benefit for DES compared with BMS in 2003 was observed, demonstrating the safety of DES, and suggesting the possibility of superiority in outcome in older patients with DES vs. BMS. However, the lack of improved survival from 2002 to 2003 in all stented patients suggests that the mortality advantage with DES finding may be due to unidentified selection biases. Our data suggest that DES in the Medicare population is as safe as, and possibly superior, to BMS for survival over the first year after implantation.
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Affiliation(s)
- Fen Wei Wang
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
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636
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Abstract
Drug-eluting stents, or intracoronary stents that combine the local delivery of antirestenotic pharmacologic therapies while maintaining the mechanical advantage of bare metal stents over balloon angioplasty alone, are a highly complex technology that have profoundly affected the practice of percutaneous coronary intervention over the last 5 years. These devices were designed specifically to treat the neointimal hyperplasia occurring after conventional bare metal stent placement, and have been remarkably successful in this regard. However, recent concerns have been raised regarding the long-term safety of these devices, particularly when used outside of the specific patient and lesion subsets studied in the pivotal randomized trials that led to device approval by regulatory bodies within the United States and abroad. This review aims to present a brief description of the sirolimus-eluting stent device platform and its mechanism of action, followed by an overview of current data regarding efficacy and safety regarding the clinical use of sirolimus-eluting stent technology.
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Affiliation(s)
- Ajay J Kirtane
- Center for Interventional Vascular Therapy, Columbia University Medical Center, New York, NY 10032, USA.
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637
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Canibus P, Faloia E, Piva T, Muçai A, Serenelli M, Perna GP, Boscaro M, Piva R. Metabolic syndrome does not increase angiographic restenosis rates after drug-eluting stent implantation. Metabolism 2008; 57:593-7. [PMID: 18442619 DOI: 10.1016/j.metabol.2007.10.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Accepted: 10/29/2007] [Indexed: 12/19/2022]
Abstract
Metabolic syndrome (MS) is associated with an increased risk of coronary heart disease, stroke, and cardiovascular mortality; but its effect on patients undergoing cardiac revascularization is still unclear. Robust evidence demonstrates that diabetes mellitus and insulin resistance are among the main risk factors for restenosis in patients requiring percutaneous myocardial revascularization. The recent advent of drug-eluting stents (DESs) has significantly reduced the incidence of restenosis compared with bare-metal stents, both in nondiabetic and in diabetic patients. The aim of the study was to evaluate the effect of MS on the risk of binary restenosis in DES implant recipients. One hundred eighty-nine recipients of successful DES implants performed between January and March 2005 for stable coronary artery disease underwent 1-year clinical and angiographic follow-up. Body mass index (BMI), blood pressure, fasting blood glucose, and lipid profile were determined. Metabolic syndrome was defined according to the National Cholesterol Education Program Adult Treatment Panel III criteria, with the waist criterion being substituted by a BMI>or=28.8 kg/m2. Metabolic and anthropometric information for MS diagnosis was available for 148 of 189 patients; 87 of 148 patients (58%) had MS. Patients with MS had higher BMI (28.4+/-3.8 vs 26+/-2.7 kg/m2, P<.0001), systolic blood pressure (133+/-14 vs 124+/-14 mm Hg, P=.0004), and fasting glucose (113+/-37 vs 92+/-17 mg/dL, P<.0001). They also had higher serum triglycerides (154+/-94 vs 113+/-43, P=.0018) and lower high-density lipoprotein cholesterol levels (39+/-9 vs 46+/-10, P<.0001). Rates of restenosis (10.5% vs 8.1%, P=not significant [NS]), target vessel revascularization (10.5% vs 11.3%, P=NS), and major adverse cardiac events (11.6% vs 14.5%, P=NS) were not significantly different in patients with MS compared with those without MS, nor was any association found between increased end point risk and presence of MS. When patients were subdivided into 6 subgroups by the presence of 0, 1, 2, 3, 4, or 5 of the MS components, restenosis rates were not significantly different among subgroups. In conclusion, MS is not associated with higher rates of restenosis, target vessel revascularization, or major adverse cardiac events; and no additional MS feature was associated with an increased risk.
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Affiliation(s)
- Paola Canibus
- Division of Endocrinology, Polytechnic University of Marche, and Department of Cardiovascular Diseases, G.M. Lancisi Hospital, Ancona, Italy
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638
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Dani S, Kukreja N, Parikh P, Joshi H, Prajapati J, Jain S, Thanvi S, Shah B, Dutta JP. Biodegradable-polymer-based, sirolimus-eluting Supralimus® stent: 6-month angiographic and 30-month clinical follow-up results from the Series I prospective study. EUROINTERVENTION 2008; 4:59-63. [DOI: 10.4244/eijv4i1a11] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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639
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Iijima R, Ndrepepa G, Mehilli J, Dirschinger J, Pache J, Seyfarth M, Schömig A, Kastrati A. Effect of abciximab on clinical and angiographic restenosis in patients with non-ST-segment elevation acute coronary syndromes. Am J Cardiol 2008; 101:1226-31. [PMID: 18435948 DOI: 10.1016/j.amjcard.2007.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Revised: 12/19/2007] [Accepted: 12/19/2007] [Indexed: 10/22/2022]
Abstract
The ISAR-REACT 2 trial was designed to assess the effect of abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after a 600-mg loading dose of clopidogrel. The aim of the present study was to investigate the impact of abciximab on clinical and angiographic restenosis after coronary stenting in patients with acute coronary syndromes. The angiographic substudy included 1,544 patients from the ISAR-REACT 2 trial randomly assigned to abciximab (771 patients) or placebo (773 patients). All patients were scheduled for routine angiographic follow-up at 6 to 8 months after intervention. The primary end point was incidence of angiographic in-segment binary restenosis. The secondary end point was 1-year incidence of target-lesion revascularization. Binary restenosis was observed in 21.9% of patients in the abciximab group and 24.5% of patients in the placebo group (p=0.29). Percentages of in-stent (29+/-22% vs 33+/-24%; p=0.02) and in-segment (35+/-20% vs 38+/-21%; p=0.04) diameter stenoses were significantly lower in the abciximab group than the placebo group. There was a strong trend toward lower 1-year incidence of target-lesion revascularization in patients treated with abciximab than in patients treated with placebo (13.6% vs 16.8%; p=0.08). In conclusion, in patients with non-ST-segment elevation acute coronary syndromes undergoing early percutaneous coronary intervention with stenting after a 600-mg loading dose of clopidogrel, abciximab therapy may have a slight positive impact on the prevention of restenosis.
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640
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Atallah AN. Primum non nocere. Quomo sapere? Firstly, do no harm. How can we know this? Drug-eluting stents versus surgery. SAO PAULO MED J 2008; 126:143-4. [PMID: 18711651 PMCID: PMC11026012 DOI: 10.1590/s1516-31802008000300001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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641
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642
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Long-Term Outcome in Patients Treated With Sirolimus-Eluting Stents in Complex Coronary Artery Lesions. J Am Coll Cardiol 2008; 51:2011-6. [PMID: 18498953 DOI: 10.1016/j.jacc.2008.01.056] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 01/04/2008] [Accepted: 01/07/2008] [Indexed: 11/20/2022]
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643
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Bhatt SH, Hauser TH. Very Late Stent Thrombosis After Dual Antiplatelet Therapy Discontinuation in a Patient with a History of Acute Stent Thrombosis. Ann Pharmacother 2008; 42:708-12. [DOI: 10.1345/aph.1k647] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To describe a case of very late stent thrombosis after dual antiplatelet discontinuation in a patient with a previous history of stent thrombosis. Case Summary: A 62-year-old man with a history of coronary artery disease, multiple acute coronary syndromes requiring percutaneous coronary interventions with multiple stent placements, and acute stent thrombosis resulting in ST segment elevation myocardial infarction presented to the hospital with chest pain. The chest pain was not relieved by 4 sublingual nitroglycerin tablets. Five days prior to his presentation, the patient had been instructed to discontinue both aspirin and clopidogrel in preparation for a left ankle fusion procedure. He was taken to the cardiac catheterization laboratory where he was found to have thrombosis in a sirolimus-eluting stent placed more than 3 years ago. Thrombectomy and balloon angioplasty were performed, and the patient completed his hospital course without complications. Discussion: Stent thrombosis associated with drug-eluting stents is a complicated pathophysiologic phenomenon with multiple patient-, procedure-, and device-related factors. Application of these risk factors to quantify the risk of stent thrombosis as they apply to a single patient is unknown. Discontinuation of recommended dual antiplatelet therapy with aspirin plus a thienopyridine has been identified as a major risk factor for stent thrombosis, but the optimal duration of dual antiplatelet therapy remains unknown. Current recommendations suggest extending dual antiplatelet therapy beyond one year in patients with low bleeding risk. Conclusions: Given the overall data at this time and the severity of stent thrombosis, it seems prudent to continue dual antiplatelet therapy with aspirin indefinitely plus a thienopyridine for at least one year, with continuation beyond one year on a case-by-case basis depending on the risks of in-stent thrombosis and bleeding. In patients with a low risk of bleeding, indefinite continuation of dual antiplatelet therapy may be reasonable.
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Affiliation(s)
- Snehal H Bhatt
- Pharmacy Practice, Department of Pharmacy Practice,
Massachusetts College of Pharmacy and Health Sciences, Boston,
MA
| | - Thomas H Hauser
- Nuclear Cardiology, Beth Israel Deaconess Medical
Center; Assistant Professor of Medicine, Harvard Medical School,
Boston
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644
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Daemen J, Kukreja N, van Twisk PH, Onuma Y, de Jaegere PPT, van Domburg R, Serruys PW. Four-year clinical follow-up of the rapamycin-eluting stent evaluated at Rotterdam Cardiology Hospital registry. Am J Cardiol 2008; 101:1105-11. [PMID: 18394442 DOI: 10.1016/j.amjcard.2007.11.074] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Revised: 11/29/2007] [Accepted: 11/29/2007] [Indexed: 11/30/2022]
Abstract
Although the safety of drug-eluting stents has been under considerable scrutiny, limited real-world follow-up data extending up to 4 years are available. The randomized clinical trials carefully selected patients and are not reflective of everyday practice. From April to October 2002, 508 consecutive patients treated with sirolimus-eluting stents (SES) were enrolled. The control group consisted of 450 patients treated with bare-metal stents during the preceding 6 months. After 4 years of follow-up, the incidence of composite major adverse clinical events (all-cause death, myocardial infarction, or target vessel revascularization) was found to be significantly lower in the SES group (23.0% vs 28.7%, adjusted hazard ratio 0.66, 95% confidence interval 0.51 to 0.86), as were rates of target vessel revascularization (12.2% vs 17.8%, adjusted hazard ratio 0.57, 95% confidence interval 0.39 to 0.83). There were no differences in all-cause mortality (10.5% for SES vs 10.6% for bare-metal stents, p = 0.9) or in the rates of cardiac death (4.5% vs 6.9%, p = 0.1). Although there was no difference in overall stent thrombosis (2.3% vs 2.2%, p = 1.0), SES had a higher rate of very late stent thrombosis (1.4% vs 0%, p = 0.02), balanced by a lower rate of early stent thrombosis (0.4% vs 1.8%, p = 0.05). In conclusion, after 4 years, SES were found to remain safe and effective compared with bare-metal stents. Nevertheless, the higher rate of very late stent thrombosis remains a concern. Longer term follow-up will be required to determine the extent of this problem.
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Affiliation(s)
- Joost Daemen
- Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
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645
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Safety of drug-eluting stents. ACTA ACUST UNITED AC 2008; 5:316-28. [DOI: 10.1038/ncpcardio1189] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2007] [Accepted: 01/31/2008] [Indexed: 12/22/2022]
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646
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Hannan EL, Racz M, Holmes DR, Walford G, Sharma S, Katz S, Jones RH, King SB. Comparison of coronary artery stenting outcomes in the eras before and after the introduction of drug-eluting stents. Circulation 2008; 117:2071-8. [PMID: 18391112 DOI: 10.1161/circulationaha.107.725531] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Few studies have compared medium-term outcomes for drug-eluting stents (DES) and bare metal stents, and most are relatively small randomized controlled trials. Furthermore, since the introduction of DES, there has been increased use and duration of use of clopidogrel, statins, and other evidence-based therapies. The purpose of the present study was to compare outcomes for patients who underwent stenting in the eras before and after the introduction of DES. METHODS AND RESULTS New York state patients undergoing stenting in all nonfederal hospitals in the state were studied. Patients were excluded if they had a previous revascularization. Risk factors that were significant predictors of adverse outcomes were used to adjust adverse outcome rates. The study included 11,436 patients who received stents between October 1, 2002, and March 31, 2003, and 12,926 patients who underwent stenting between October 1, 2003, and March 31, 2004. Death rates, the combined end point of death and myocardial infarction (MI), nonfatal MI requiring readmission, target vessel revascularization, and target lesion revascularization were compared at 2 years. Patients in the DES era had significantly better risk-adjusted outcomes for death/MI (adjusted hazard ratio, 0.90; 95% confidence interval, 0.83 to 0.97), 9.9% versus 10.8%; nonfatal MI requiring readmission (adjusted hazard ratio, 0.86; 95% confidence interval, 0.76 to 0.97); target vessel revascularization (adjusted hazard ratio, 0.60; 95% confidence interval, 0.56 to 0.64), 11.2% versus 17.9%; and target lesion revascularization (hazard ratio, 0.55; 95% confidence interval, 0.51 to 0.59), 8.4% versus 14.7%. CONCLUSIONS Patients in the DES era experienced lower rates of death/MI, nonfatal MI, target vessel revascularization, and target lesion revascularization, but there were no differences in the rates of death. These improvements are likely a result of increased use of clopidogrel, statins, and dual antiplatelet therapy, in addition to the introduction of DES.
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Affiliation(s)
- Edward L Hannan
- School of Public Health, State University of New York, University at Albany, One University Place, Rensselaer, NY 12144-3456, USA.
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647
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Ducrocq G, Serebruany V, Tanguay JF. Antiplatelet therapy in the era of drug-eluting stents: current and future perspectives. Expert Rev Cardiovasc Ther 2008; 5:939-53. [PMID: 17867923 DOI: 10.1586/14779072.5.5.939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The use of drug-eluting stents (DESs) dramatically reduced in-stent restenosis. However, the increasing use of these stents has raised concern about their potential thrombogenicity. Indeed, the particularity of DES thrombosis compared with bare metal stent thrombosis is a high rate of late thrombosis. Antiplatelet therapy is efficient in preventing DES thrombosis. However, this therapy could be optimized and may be improved in the future. This article will review the mechanisms and the epidemiology of stent thrombosis. Then, we will summarize the antiplatelet therapeutic strategies used to prevent stent thrombosis and especially DES-associated thrombosis. Finally, we will present some data with regard to potential advantages and pitfalls in DES thrombosis prevention using novel antiplatelet agents currently under development, as well as future stent designs with improved healing properties.
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Affiliation(s)
- Gregory Ducrocq
- Université de Montréal, Institut de Cardiologie de Montréal, Research Centre, Department of Medicine, 5000, rue Bélanger, Montréal, Qc H1T 1C8, Canada
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648
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Chen JP, Crisco LV, Jabara R, King SB. Late angiographic stent thrombosis: the LAST straw for drug-eluting stents? Angiology 2008; 59:667-75. [PMID: 18388045 DOI: 10.1177/0003319707310279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The long-term patency advantage of drug-eluting stents represents a quantum leap in the percutaneous treatment of ischemic heart disease. Although initial landmark trials demonstrated equivalent safety to bare-metal stents, subsequent follow-up analyses have suggested a slight late thrombotic risk. This widely publicized issue poses major public health implications for the medical and lay communities. However, available data indicate that this late risk is counterbalanced by the dramatic drug-eluting stent reduction in target lesion revascularizations, resulting in equivalent overall major adverse cardiovascular event rates than that of the bare-metal stents The recent Food and Drug Administration's guidelines regarding these devices are delineated in detail. Specifically, compliance with dual antiplatelet therapy (minimum 1 year) is of paramount consideration in patient selection for drug-eluting stents. Moreover, when deployed for "on-label" indications, they provide significant restenosis advantage, with a slight late thrombotic risk but without overall increase in death or infarction.
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Affiliation(s)
- Jack P Chen
- Department of Cardiology, Saint Joseph's Hospital of Atlanta, Atlanta, Georgia, USA.
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649
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Planas-del Viejo AM, Pomar-Domingo F, Vilar-Herrero JV, Jacas-Osborn V, Nadal-Barangé M, Pérez-Fernández E. Resultados clínicos y angiográficos tardíos de stents liberadores de fármacos en pacientes con infarto agudo de miocardio con elevación del ST. Rev Esp Cardiol 2008. [DOI: 10.1157/13117727] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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650
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SCHNEIDER MICHAELAE, HOCH FRANZV, NEUSER HANS, BRUNN JÜRGEN, KOLLER MARCUSL, GIETZEN FRANK, SCHAMBERGER RAINER, KERBER SEBASTIAN, SCHUMACHER BURGHARD. Magnetic-Guided Percutaneous Coronary Intervention Enabled by Two-Dimensional Guidewire Steering and Three-Dimensional Virtual Angioscopy: Initial Experiences in Daily Clinical Practice. J Interv Cardiol 2008; 21:158-66. [DOI: 10.1111/j.1540-8183.2007.00327.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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