Comparison of zotarolimus-eluting stents with sirolimus- and paclitaxel-eluting stents for coronary revascularization: the ZEST (comparison of the efficacy and safety of zotarolimus-eluting stent with sirolimus-eluting and paclitaxel-eluting stent for coronary lesions) randomized trial

Sex difference in clinical outcomes after percutaneous coronary intervention in Korean population

BACKGROUND

Conflicting data on sex-based differences in outcomes after percutaneous coronary intervention (PCI) among Western population exist. Little is known about the nature of sex-specific PCI outcomes in an Asian population.

METHODS

We performed a pooled analysis using 23,604 patients from 11 prospective PCI clinical studies performed in Korea. The primary outcome was a major cardiovascular event, defined as composite of cardiovascular death, myocardial infarction, stent thrombosis, or stroke. Secondary outcomes were all-cause mortality and target vessel revascularization.

RESULTS

Thirty-day and 2-year rates of major cardiovascular events were more frequent in women than in men, mainly because of a higher incidence of periprocedural myocardial infarction in women (30-day: 9.2% vs 7.1%; 2-year: 11.2% vs 8.9%). After multivariable adjustment, women had significantly higher risks of 30-day (hazard ratio [HR] 1.27, 95% CI 1.19-1.36) and 2-year major cardiovascular events (HR 1.21, 95% CI 1.13-1.30). Unadjusted 30-day and 2-year all-cause mortality was similar between women and men (30-day: 0.5% vs 0.4%; 2-year: 2.8% vs 2.8%). However, after multivariable adjustment, women had a lower adjusted risk of 2-year death (HR 0.82, 95% CI 0.77-0.87). No sex-based difference was observed for target vessel revascularization (HR 1.07, 95% CI 0.91-1.25). Overall, sex-specific findings for outcomes were consistent across multiple patient subgroups.

CONCLUSION

Among Korean population undergoing contemporary PCI, women have a significantly higher risk of short- and long-term major cardiovascular events than do men but have better long-term survival.

Impact of the angiographic mechanisms underlying periprocedural myocardial infarction after drug-eluting stent implantation

Periprocedural myocardial infarction (MI) can be induced by several angiographic mechanisms. However, there are limited data on whether these mechanisms differentially affect clinical outcomes. The purpose of our study was to investigate the impact of periprocedural MI on mortality according to the underlying angiographic mechanisms after drug-eluting stent (DES) implantation. We pooled the databases from 7 coronary stent trials using DES. Periprocedural MI was classified according to its underlying angiographic mechanisms as type 1 (due to side-branch occlusion), type 2 (due to other angiographic complications), or type 3 (without angiographically identifiable causes). Among 10,889 patients treated with DES, 768 (7.1%) experienced periprocedural MI; 463 cases (60.3%) were driven by type 1 cause, 138 (18.0%) by type 2 cause, and 167 (21.7%) by type 3 cause. Mortality rates at 2 years were higher in patients with periprocedural MI than in those without (3.5% vs 2.1%, respectively). Significant differences in mortality were observed according to the angiographic mechanisms of MI (type 1: 2.8% vs type 2: 6.1% vs type 3: 3.1%). After multivariable adjustment, type 2 MI was significantly associated with an increased risk of mortality (hazard ratio 2.65, 95% confidence interval 1.77 to 3.96), whereas type 1 and type 3 MI were not related with increased mortality. In conclusion, among patients receiving DES implantation, periprocedural MI was associated with increased mortality, and there were differential associations with mortality according to the underlying angiographic mechanisms.

Therapy in ST-elevation myocardial infarction: reperfusion strategies, pharmacology and stent selection

OPINION STATEMENT

The estimated annual incidence of new and recurrent myocardial infarction (MI) in the U.S. is 715,000 events. Primary percutaneous coronary intervention (PCI) is the reperfusion strategy of choice in most patients with acute ST-elevation myocardial infarction (STEMI). Recent advances in percutaneous techniques and devices, including manual aspiration catheters and newer generation drug eluting stents and pharmacologic therapies, such as novel antiplatelets and anticoagulants have led to significant improvements in the acute and long-term outcomes for these patients. Implementation of community-wide systems directed to shorten treatment times tied to closely monitored quality improvement processes have led to further advances in STEMI care. Recent data suggests that transradial access for primary PCI is associated with improved outcomes. This contemporary review discusses the strategies for reperfusion, pharmacological therapy and stent selection process involved in STEMI.

Modifying effect of dual antiplatelet therapy on incidence of stent thrombosis according to implanted drug-eluting stent type

AIM

To investigate the putative modifying effect of dual antiplatelet therapy (DAPT) use on the incidence of stent thrombosis at 3 years in patients randomized to Endeavor zotarolimus-eluting stent (E-ZES) or Cypher sirolimus-eluting stent (C-SES).

METHODS AND RESULTS

Of 8709 patients in PROTECT, 4357 were randomized to E-ZES and 4352 to C-SES. Aspirin was to be given indefinitely, and clopidogrel/ticlopidine for ≥ 3 months or up to 12 months after implantation. Main outcome measures were definite or probable stent thrombosis at 3 years. Multivariable Cox regression analysis was applied, with stent type, DAPT, and their interaction as the main outcome determinants. Dual antiplatelet therapy adherence remained the same in the E-ZES and C-SES groups (79.6% at 1 year, 32.8% at 2 years, and 21.6% at 3 years). We observed a statistically significant (P = 0.0052) heterogeneity in treatment effect of stent type in relation to DAPT. In the absence of DAPT, stent thrombosis was lower with E-ZES vs. C-SES (adjusted hazard ratio 0.38, 95% confidence interval 0.19, 0.75; P = 0.0056). In the presence of DAPT, no difference was found (1.18; 0.79, 1.77; P = 0.43).

CONCLUSION

A strong interaction was observed between drug-eluting stent type and DAPT use, most likely prompted by the vascular healing response induced by the implanted DES system. These results suggest that the incidence of stent thrombosis in DES trials should not be evaluated independently of DAPT use, and the optimal duration of DAPT will likely depend upon stent type (Clinicaltrials.gov number NCT00476957).

Use of drug-eluting stents in acute myocardial infarction with persistent ST-segment elevation: results of the ALKK PCI-registry

BACKGROUND

Drug-eluting stents (DES) reduce the rate of in-stent restenosis (ISR) and target vessel revascularization significantly when compared with bare metal stents (BMS). Their beneficial effects have been demonstrated in patients with acute myocardial infarction also, but the use of DES in the latter population seems to be still limited in clinical practice.

METHODS AND RESULTS

From January 2006 to December 2011, 25,424 patients with ST-elevation myocardial infarction were enrolled in the German ALKK PCI-registry. In 5,467 patients (21.5 %), a DES was implanted in the culprit segment, in 16,911 patients (66.5 %) a BMS, and 2,959 patients (11.6 %) received neither DES nor BMS. The rates of DES for typical subgroups were 31.7 % in patients with diabetes, 36.6 % in unprotected left main stenosis, 32.4 % in ostial lesions, 32.0 % for a stent length >15 mm, 26.2 % for a stent diameter ≤3 mm, and 58.5 % for ISR. There was a wide range in the use of DES between the different ALKK hospitals with a minimum of 2.3 % and a maximum of 58.3 % for the total study period (median 22.0 %, quartiles 14.6 and 37.5 %).

CONCLUSIONS

Despite convincing data for the use of DES in patients with STEMI, there is still an underuse of DES in this clinical setting in Germany. This is particularly worrying for the subgroups of patients and lesions with a high risk of restenosis. Further efforts are needed to reduce the skepticism about DES and to improve guideline adherent treatment.

A bumpy and winding but right path to domestic drug-eluting coronary stents

Restenosis and stent thrombosis remain major concerns after percutaneous coronary intervention for the treatment of coronary artery disease. The present review was undertaken in order to highlight the various coronary stents that have been investigated in our Heart Research Center, and how far we have come from the first heparin-coated stent first used in the late 1990s. Thereafter, from the abciximab-coated stent to the current gene-delivery stent and other newer agents, our group has applied a range of techniques in this field. However, in groups similar to ours, the restenosis rates of such stents are still high for second-generation drug-eluting stents (DESs). Moreover, our nation imports almost all of these types of stents from other countries. Thus, we need to develop domestic coronary stents. Research into newer DESs are warranted in Korea so as to achieve improved safety and efficacy outcomes.

Safety and efficacy outcomes of first and second generation durable polymer drug eluting stents and biodegradable polymer biolimus eluting stents in clinical practice: comprehensive network meta-analysis

OBJECTIVES

To investigate the safety and efficacy of durable polymer drug eluting stents (DES) and biodegradable polymer biolimus eluting stents (biolimus-ES).

DESIGN

Network meta-analysis of randomised controlled trials.

DATA SOURCES AND STUDY SELECTION

Medline, Google Scholar, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) database search for randomised controlled trials comparing at least two of durable polymer sirolimus eluting stents (sirolimus-ES) and paclitaxel eluting stents (paclitaxel-ES), newer durable polymer everolimus eluting stents (everolimus-ES), Endeavor and Resolute zotarolimus eluting stents (zotarolimus-ES), and biodegradable polymer biolimus-ES.

PRIMARY OUTCOMES

Safety (death, myocardial infarction, definite or probable stent thrombosis) and efficacy (target lesion and target vessel revascularisation) assessed at up to one year and beyond.

RESULTS

60 randomised controlled trials were compared involving 63,242 patients with stable coronary artery disease or acute coronary syndrome treated with a DES. At one year, there were no differences in mortality among devices. Resolute and Endeavor zotarolimus-ES, everolimus-ES, and sirolimus-ES, but not biodegradable polymer biolimus-ES, were associated with significantly reduced odds of myocardial infarction (by 29-34%) compared with paclitaxel-ES. Compared with everolimus-ES, biodegradable polymer biolimus-ES were associated with significantly increased odds of myocardial infarction (by 29%), while Endeavor zotarolimus-ES and paclitaxel-ES were associated with significantly increased odds of stent thrombosis. All investigated DES were similar with regards to efficacy endpoints, except for Endeavor zotarolimus-ES and paclitaxel-ES, which were associated with significantly increased the odds of target lesion and target vessel revascularisations compared with other devices. Direction of results beyond one year did not diverge from the findings for up to one year follow-up. Bayesian probability curves showed a gradient in the magnitude of effect, with everolimus-ES and Resolute zotarolimus-ES offering the highest safety profiles.

CONCLUSIONS

The newer durable polymer everolimus-ES and Resolute zotarolimus-ES and the biodegradable polymer biolimus-ES maintain the efficacy of sirolimus-ES; however, for safety endpoints, differences become apparent, with everolimus-ES and Resolute zotarolimus-ES emerging as the safest stents to date.

Randomized comparison of Zotarolimus-Eluting Endeavor Sprint versus bare-metal stent implantation in uncertain drug-eluting stent candidates: rationale, design, and characterization of the patient population for the Zotarolimus-eluting Endeavor Sprint stent in uncertain DES candidates study

BACKGROUND

The use of drug-eluting stent (DES) instead of bare-metal stent (BMS) in patients at high stent thrombosis or bleeding risk as well as in those at low restenosis risk (ie, uncertain DES candidates) remains a matter of debate. Zotarolimus-Eluting Endeavor Sprint stent (E-ZES) (Santa Rosa, CA) is a hydrophilic polymer-based second-generation device with unique drug fast-release profile, which may allow for a shorter dual antiplatelet therapy (DAPT) duration without safety concerns.

HYPOTHESIS

The primary objective is to assess whether E-ZES implantation followed by a shorter than currently recommended course of DAPT will decrease the incidence of 12-month major adverse cardiovascular events as compared with BMS in undefined DES recipients. Actual duration of DAPT regimen will be dictated by patients' characteristics and not by stent type and, as such, can be as short as 30 days after intervention in both stent groups.

STUDY DESIGN

The ZEUS study is an open-label randomized clinical trial conducted at 20 clinical sites in Italy, Switzerland, Portugal, and Hungary. With 1,600 individuals, this study will have 85% power to detect a 33% difference in the primary end point consisting of the composite of death, nonfatal myocardial infarction, or target vessel revascularization.

SUMMARY

The ZEUS trial aims to assess whether the use of E-ZES, followed by a DAPT duration regimen based on patients' characteristics and not by stent type, is superior to conventional BMS implantation in undefined DES recipients who qualify for the presence of high thrombosis, bleeding, or low restenosis risk criteria.

Drug-eluting stents for acute coronary syndrome: a meta-analysis of randomized controlled trials

BACKGROUND

Drug-eluting stents (DES) are increasingly used for treatment of acute coronary syndrome (ACS). However, clinical efficacy and safety of various types of DES is not well established in these subjects. We therefore evaluated clinical utility of second-generation and first-generation DES in patients with ACS by conducting a meta-analysis.

METHODS

A search of Medline, Embase, the Cochrane databases, and Web of Science was made. Randomized controlled trials (RCTs) which compared second-generation DES (everolimus-eluting stents [EES] or zotarolimus-eluting stents [ZES]) versus first-generation DES (sirolimus-eluting stents [SES] or paclitaxe-eluting stents [PES]) in patients with ACS and provided data on clinical efficacy or safety endpoints were included. Pooled estimates were calculated using random-effects model.

RESULT

A total of 2,757 participants with ACS in 6 RCTs were included. Compared with first-generation one, second-generation DES trended to be associated with the decreased incidence of definite or probable stent thrombosis in ACS patients (risk ratio [RR]  = 0.60, 95% confidence intervals [CI] 0.33 to 1.07, p = 0.09). However, the rate of target lesion revascularization (TLR) significantly increased in second-generation DES (RR = 2.08, 95%CI 1.25 to 3.47, p = 0.005). There were no significant differences in the incidence of major adverse cardiac events (MACEs), all-cause death, cardiac death, and recurrent myocardial infarction between the two arms (all p>0.10). The second-generation EES showed a tendency towards lower risk of MACEs (p = 0.06) and a beneficial effect on reducing stent thrombosis episodes (p = 0.009), while the second-generation ZES presented an increased occurrence of MACEs (p = 0.02) and TLR (p = 0.003).

CONCLUSION

Second-generation DES, especially EES, appeared to present a lower risk of stent thrombosis, whereas second-generation ZES might increase the need for repeat revascularization in ACS patients. During coronary interventional therapy, DES class should be adequately considered in order to maximize clinical benefit of DES implantation in these specific subjects.

The impact of industry representative's visits on utilization of coronary stents

BACKGROUND

The interaction between physicians and industry is complex and essential for improvement of medical care. However, conflict of interests may affect decision process. Our aim was to test if promotional visits by industry representatives affect treatment patterns and the use of various stents during percutaneous coronary interventions.

METHODS

Medical records of 1,145 consecutive patients who underwent percutaneous coronary intervention in an academic institution over 1-year period were retrospectively reviewed and linked to presence or absence of industry representative. We compared use of bare-metal stents, drug-eluting stents (DES), and balloon catheters according to company presence.

RESULTS

A total of 1,785 stents were implanted in 1,145 patients; 60.8% were DES. More DES per case were implanted when a representative was present (1.71 ± 0.9 vs 1.60 ± 0.93, P = .023). There was no difference in the utilization of balloons and bare-metal stents between groups. Stent cost per case was higher when a representative was present (Can $1,703.5 ± 1,314.4 vs 1,468.9 ± 1,273.3, P < .001). For all companies marketing DES, there was increase in the use of the company's DES when their sale representative was present with less use of the competitors' stents.

CONCLUSIONS

Sale representative presence was associated with increased use of the representative company's stents during percutaneous coronary interventions. The effect was more pronounced on use of the company's DES and resulted in higher procedural cost.

Comparison of 3-year clinical outcomes between Resolute™ zotarolimus- and sirolimus-eluting stents for long coronary artery stenosis

OBJECTIVES

Long-term clinical outcomes were evaluated in long coronary artery stenosis treated with different types of drug-eluting stents.

BACKGROUND

Long-term follow-up data to compare clinical outcomes between Resolute™ zotarolimus-eluting stent (R-ZES) versus sirolimus-eluting stent (SES) implantation for long coronary artery stenosis is insufficient.

METHODS

A total of 254 patients (307 lesions) treated with R-ZES and 265 patients (303 lesions) treated with SES for long coronary lesions (total stent length ≥ 30 mm) were enrolled, and long-term (3 years) clinical outcomes were compared between the 2 groups. Efficacy (target lesion revascularization [TLR]) and safety (the composite occurrence of cardiovascular death, target lesion-related myocardial infarction, or target lesion-related definite stent thrombosis) were assessed.

RESULTS

The 2 groups had similar baseline characteristics except for the duration of dual antiplatelet therapy (23.4 ± 11.2 months in R-ZES-treated patients vs. 27.4 ± 13.9 months in SES-treated patients, P<0.001). Total stent length was similar in R-ZES-treated patients (45.0 ± 19.0 mm) and SES-treated patients (45.4 ± 18.6 mm) (P=0.464). The cumulative TLR rate was 4.6% in R-ZES-treated patients versus 4.6% in SES-treated patients (P=0.911). For safety parameters, R-ZES-treated patients showed a significantly lower rate of the composite occurrence of cardiovascular death, target lesion-related myocardial infarction, or target lesion-related definite stent thrombosis than SES-treated patients (0.4% vs. 2.4%, P=0.042). Particularly, the occurrence of target lesion-related definite stent thrombosis was significantly lower in R-ZES-treated patients than in SES-treated patients (0.0% vs. 2.0%, P=0.028).

CONCLUSIONS

R-ZES stents showed superior long-term safety than SES for treating long coronary lesions, while maintaining a similar clinical efficacy.

Randomized trial comparing the efficacy between different types of paclitaxel-eluting stents: the comparison of efficacy between COroflex PLEASe ANd Taxus stent (ECO-PLEASANT) randomized controlled trial

AIMS

Paclitaxel-eluting stents (PESs) have been shown to inhibit neointimal hyperplasia after percutaneous coronary intervention. Coroflex Please (B Braun, Melsungen, Germany) is a newly developed PES. We compared the clinical and angiographic efficacy of Coroflex Please with Taxus Liberte (Boston Scientific, Natick, MA) in a real-world practice.

METHODS AND RESULTS

We performed a prospective, open-label, randomized, controlled study that enrolled 945 patients undergoing percutaneous coronary interventions in 18 centers in Korea. The primary end point was clinically driven target vessel revascularization at 9 months. The baseline characteristics were mostly similar and comparable between 2 groups. At 9 months, the incidence of clinically driven target vessel revascularization was 14.6% for Coroflex and 6.4% for Taxus, which was significantly different (hazard ratio 2.43, 95% CI 1.50-3.94, noninferiority P value = 1.000). This is well corroborated by the difference of in-stent late loss between 2 stents (0.71 ± 0.64 mm vs 0.52 ± 0.50 mm, P < .001) by 9-month follow-up angiography (n = 415 vs 215). Among secondary clinical end points, stent thrombosis (definite and probable) for 1 year was 2.2% in Coroflex and 1.3% in Taxus (P = .317). Also, myocardial infarction for 9 months was higher in Coroflex group than that in Taxus (4.9% vs 1.6%, P = .012), which was partly contributed by the higher incidence of periprocedural myocardial infarction in Coroflex arm (2.2% vs 0.3%, P = .028).

CONCLUSIONS

Coroflex Please was inferior to Taxus Liberte with regard to clinical and angiographic efficacy.

Association of body mass index with major cardiovascular events and with mortality after percutaneous coronary intervention

BACKGROUND

Conflicting data exist regarding the relation between body mass index (BMI) and cardiovascular events and mortality after percutaneous coronary intervention.

METHODS AND RESULTS

We performed pooled analyses to evaluate the association between BMI (weight in kilograms divided by the square of the height in meters) and the risks of major cardiovascular events (defined as death from cardiovascular causes, nonfatal myocardial infarction, stent thrombosis, or stroke) and death among 23 181 patients from 11 prospective percutaneous coronary intervention studies. Overall, mean (±SD) BMI was 24.9±3.0. During follow-up (median, 2.1 years), 2381 patients had a major cardiovascular event, and 1004 patients died. After adjusting covariates, there was an inverse relationship between BMI and adverse outcomes. With a BMI of 22.5 to 24.9 as the reference category, the risk of major cardiovascular events was elevated among patients with a lower BMI (by a factor of 1.52 for a BMI <18.5; 1.05 for a BMI of 18.5-19.9; 1.03 for a BMI of 20.0-22.4); by contrast, the risk declined among patients with a higher BMI (by a factor of 0.97 for a BMI of 25.0-27.4; 0.97 for a BMI of 27.5-29.9; and 0.78 for a BMI of ≥30.0). In general, the hazard ratios for deaths were similar.

CONCLUSIONS

Among patients undergoing percutaneous coronary intervention, a low BMI was associated with increased risks of major cardiovascular events and death. However, there were no excess risks of these events associated with a high BMI.

Frequency, causes, predictors, and clinical significance of peri-procedural myocardial infarction following percutaneous coronary intervention

AIMS

Peri-procedural myocardial infarction (MI) is a not infrequent complication of percutaneous coronary intervention (PCI), but conflicting information exists regarding incidence and prognostic impact of this event. We investigated frequency, causes, predictors, and clinical relevance of peri-procedural MI, using a large database.

METHODS AND RESULTS

We pooled individual patient-level data from 11 PCI studies in which peri-procedural creatine kinase-MB mass was routinely measured and mortality data were prospectively collected. Among 23 604 patients from 11 studies, 1677 {7.1% [95% confidence interval (CI) 6.8-7.5%]} had peri-procedural MI. The most common mechanism of peri-procedural MI was side-branch occlusion. Independent predictors of peri-procedural MI were older age, female gender, diabetes, hypertension, renal dysfunction, multivessel disease, left anterior descending artery disease, left main disease, bifurcation lesion, long lesion, drug-eluting stents, and number of stents. Follow-up varied from 1 year to 5 years. In a crude analysis, patients with peri-procedural MI had significantly a higher risk of mortality than those without peri-procedural MI [hazard ratio (HR) 1.47; 95% CI 1.24-1.74]. After adjustment for baseline covariates, peri-procedural MI was associated with an increased risk of mortality (HR 1.20; 95% CI 1.04-1.39).

CONCLUSION

Among patients undergoing PCI, the occurrence of peri-procedural MI measured by CK-MB mass assay was ~7%, and more than half of cases were associated with side-branch occlusion. Several higher risk patients, lesions, and procedural characteristics were independent predictors of peri-procedural MI. Peri-procedural MI was associated with an increase in mortality.

The effects of lyophilization on the physico-chemical stability of sirolimus liposomes

PURPOSE

The major limitation in the widespread use of liposome drug delivery system is its instability. Lyophilization is a promising approach to ensure the long-term stability of liposomes. The aim of this study was to prepare sirolimus-loaded liposomes, study their stability and investigate the effect of lyophilization either in the presence or in the absence of lyoprotectant on liposome properties.

METHODS

Two types of multi-lamellar liposomes, conventional and fusogenic, containing sirolimus were prepared by modified thin film hydration method with different ratio of dipalmitoylphosphatidylcholine (DPPC), cholesterol and dioleoylphosphoethanolamine (DOPE), and were lyophilized with or without dextrose as lyoprotectant. Chemical stability investigation was performed at 4°C and 25°C until 6 months using a validated HPLC method. Physical stability was studied with determination of particle size (PS) and encapsulation efficiency (EE %) of formulations through 6 months.

RESULTS

Chemical stability test at 4°C and 25°C until 6 months showed that drug content of liposomes decreased 8.4% and 20.2% respectively. Initial mean EE % and PS were 72.8 % and 582 nm respectively. After 6 months mean EE % for suspended form, lyophilized without lyoprotectant and lyophilized with lyoprotectant were 54.8 %, 62.3% and 67.1 % at 4°C and 48.2%, 60.4 % and 66.8 % at 25°C respectively. Corresponding data for mean PS were 8229 nm, 2397 nm and 688nm at 4°C and 9362 nm, 1944 nm and 737 nm at 25°C respectively.

CONCLUSION

It is concluded that lyophilization with and without dextrose could increase shelf life of liposome and dextrose has lyoprotectant effect that stabilized liposomes in the lyophilization process.

3-Year clinical outcomes in the randomized SORT OUT III superiority trial comparing zotarolimus- and sirolimus-eluting coronary stents

OBJECTIVES

This study sought to examine the 3-year clinical outcomes in patients treated with the Endeavor (Medtronic, Santa Rosa, California) zotarolimus-eluting stent (ZES) or the Cypher (Cordis, Johnson & Johnson, Warren, New Jersey) sirolimus-eluting stent (SES) in routine clinical practice.

BACKGROUND

The long-term clinical outcome in patients treated with ZES in comparison with SES is unclear.

METHODS

The authors randomized 2,332 patients to ZES (n = 1,162) or SES (n = 1,170) implantation. Endpoints included major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction, or target vessel revascularization; the individual endpoints of MACE; and definite stent thrombosis.

RESULTS

At 3-year follow-up, the MACE rate was higher in patients treated with ZES than in patients treated with SES (148 [12.9%] vs. 116 [10.1%]; hazard ratio [HR]: 1.33, 95% confidence interval [CI]: 1.04 to 1.69; p = 0.022). Target vessel revascularization was more frequent in the ZES group compared with the SES group (103 [9.1%] vs. 76 [6.7%]; HR: 1.40, 95% CI: 1.04 to 1.89; p = 0.025), whereas the occurrence of myocardial infarction (3.8% vs. 3.3%) and cardiac death (2.8% vs. 2.8%) did not differ significantly. Although the rate of definite stent thrombosis was similar at 3-year follow-up (1.1% vs. 1.4%), very late (12 to 36 months) definite stent thrombosis occurred in 0 (0%) patients in the ZES group versus 12 (1.1%) patients in the SES group (p = 0.0005).

CONCLUSIONS

Although the 3-year MACE rate is higher in patients treated with ZES versus SES, our data highlight a late safety problem concerning definite stent thrombosis with the use of SES. This finding underscores the importance of long-term follow-up in head-to-head comparisons of drug-eluting stents. (Randomized Clinical Comparison of the Endeavor and the Cypher Coronary Stents in Non-selected Angina Pectoris Patients [SORT OUT III]; NCT00660478).

Implementation of standardized assessment and reporting of myocardial infarction in contemporary randomized controlled trials: a systematic review

Myocardial infarction (MI) is a key endpoint in randomized controlled trials (RCTs), but heterogeneous definitions limit comparisons across RCTs or meta-analyses. The 2000 European Society of Cardiology/American College of Cardiology MI redefinition and the 2007 universal MI definition consensus documents made recommendations to address this issue. In cardiovascular randomized trials, we evaluated the impact of implementation of three key recommendations from these reports-troponin use to define MI; separate reporting of spontaneous and procedure-related MI; and infarct size reporting. We searched ClinicalTrials.gov and MEDLINE databases for cardiovascular RCTs with more than 500 patients in which enrolment began between September 2000 and July 2012 and that listed MI in the primary endpoint. We searched English-language publications with primary results or design papers. Of 3222 studies screened, 96 (3.0%) met our criteria. We extracted enrolment start date, number of patients and MI events, follow-up duration, and coronary revascularization rate. Data extraction quality was assessed by duplicated extractions. Of 96 RCTs, 80 had a primary results publication, comprising 608 091 patients and 43 621 endpoint MIs. Myocardial infarction represented 45.3% (95% confidence interval, 40.2-50.4) of events in the primary composite endpoint. Troponin defined MI in 57% (53/93) of trials with an MI definition available. Of these RCTs, three used troponin only if creatine kinase-MB was unavailable, six used troponin to define peri-procedural MI, seven specified the 99th percentile as the MI decision limit, and three reported spontaneous and procedure-related MI separately. None reported biomarker-based infarct size, but five reported MI as multiples of the assay upper limit of normal. Although MI is a major component of cardiovascular RCT primary endpoints, standardized MI reporting and implementation of consensus document recommendations for MI definition are limited. Developing appropriate strategies for uniform implementation is required.

Coronary stent thrombosis: current insights into new drug-eluting stent designs

The advances of interventional cardiology have been achieved by new device development, finding appropriate drug regimes, and understanding of pathomechanism. Drug-eluting stents (DES) implantation with dual anti-platelet therapy reduced revascularization without increasing mortality or myocardial infarction compared with bare-metal stenting. However, late-term stent thrombosis (ST) and restenosis limited its value and raised the safety concern. Main mechanisms of this phenomenon are impaired endothelialization and hypersensitivity reaction with polymer. The second generation DES further improved safety and/or efficacy by using thinner stent strut and biocompatible polymer. Recently, new concept DES with biodegradable polymer, polymer-free and bioabsorbable scaffold are under investigation in the quest to minimize the risk of ST.

Clinical outcomes after treatment of multiple lesions with zotarolimus-eluting versus sirolimus-eluting coronary stents (a SORT OUT III substudy)

Background

Data on clinical outcomes among patients treated with the zotarolimus-eluting Endeavor™ stent versus the sirolimus-eluting Cypher™ stent favor the sirolimus-eluting stent. However, a separate comparison of clinical outcome among patients treated for multiple lesions with these stents is lacking. We performed this comparison within the SORT OUT III trial data set.

Methods

Among 2332 patients randomized in SORT OUT III, 695 were treated for multiple lesions with zotarolimus-eluting (n = 350) or sirolimus-eluting (n = 345) stents and followed for 18 months. Major adverse cardiac events (MACE); composite of cardiac death, myocardial infarction, or target vessel revascularization (TVR); was the primary endpoint.

Results

Zotarolimus-eluting compared to sirolimus-eluting stent treatment was associated with increased MACE rate (13.2% vs. 2.6%; hazard ratio 5.29 with 95% confidence interval: 2.59-10.8). All secondary endpoints; all cause death, cardiac death, myocardial infarction, TVR, target lesion revascularization, in-stent restenosis, and definite stent thrombosis; were observed more frequently among zotarolimus-eluting stent treated patients. For all endpoints, hazard ratios were 1.6 to 4.6 times higher than in the overall results of the SORT OUT III trial.

Conclusions

We observed better clinical outcomes among patients treated for multiple lesions with the sirolimus-eluting stent compared to those treated with the zotarolimus-eluting stent.

Acute and long-term angiographic outcomes of side branch stenosis after randomized treatment of zotarolimus-, sirolimus-, and paclitaxel-eluting stent for coronary artery stenosis

This was designed to assess the outcomes of side branch (SB) stenosis after implantation of three drug-eluting stents (DES). From 2,645 patients in the ZEST (Comparison of the Efficacy and Safety of Zotarolimus-Eluting Stent with Sirolimus-Eluting and PacliTaxel-Eluting Stent for Coronary Lesions) Trial, 788 patients had 923 bifurcation lesions with SB ≥ 1.5 mm were included. SB was treated in 150 lesions, including 35 (3.8%) receiving SB stenting. Of untreated SB with baseline stenosis < 50%, the incidences of periprocedural SB compromise was similar in the zotarolimus (15.8%), sirolimus (17.2%), and paclitaxel (16.6%) stent groups (P = 0.92). At follow-up angiography, delayed SB compromise occurred in 13.9%, 3.2%, and 9.4% (P = 0.010) of these groups. When classified into four groups (< 50%, 50%-70%, 70%-99%, and 100%), 9.0% of untreated SB were worsened, whereas improvement and stationary were observed in 9.6% and 81.4%. In a multivariable logistic regression model, main branch (MB) stenosis at follow-up (%) was the only independent predictor of SB stenosis worsening (odds ratio, 1.03; 95% confidence interval, 1.01-1.04; P < 0.001). After MB stenting in bifurcation lesions, a minority of SB appears to worsen. DES with strong anti-restenotic efficacy may help maintain SB patency.

Zotarolimus-eluting stent versus sirolimus-eluting and paclitaxel-eluting stents for percutaneous coronary intervention: a meta-analysis of randomized trials

BACKGROUND

The zotarolimus-eluting stent (ZES) is a new drug-eluting stent that delivers zotarolimus, a synthetic analogue of sirolimus, through a biocompatible phosphorylcholine polymer coating. ZES has shown promising results compared with bare-metal stents, but its safety and efficacy against sirolimus-eluting (SES) and paclitaxel-eluting (PES) stents is yet to be established.

AIMS

We aimed to summarize current evidence from randomized trials comparing ZES with SES and PES.

METHODS

We searched the Medline, Embase and CENTRAL databases for randomized studies comparing ZES with SES and PES for percutaneous coronary intervention. Relevant clinical and angiographic outcomes were extracted and combined using random and fixed-effect models for heterogeneous and homogenous outcomes, respectively.

RESULTS

Seven randomized trials met the inclusion criteria: ZES group, n=3787; SES group, n=2606; PES group, n=1966. Compared with SES, ZES was associated with significantly higher odds of clinically driven target vessel revascularization (odds ratio [OR] 2.36, 95% confidence interval [CI] 1.78-3.14) and target lesion revascularization (OR 2.46, 95% CI 1.36-4.46). Compared with SES, ZES had higher in-stent restenosis (OR 6.13, 95% CI 3.96-9.50), late lumen loss 'in-stent' (mean difference [MD] 0.39 mm, 95% CI 0.34-0.44) and late lumen loss 'in-segment' (MD 0.18 mm, 95% CI 0.15-0.21). ZES was associated with higher in-stent late lumen loss than PES (MD 0.18 mm, 95% CI 0.07-0.28). There were no differences in mortality, reinfarction or stent thrombosis with ZES compared with SES and PES.

CONCLUSION

ZES is not superior to PES and is inferior to SES in terms of angiographic outcomes and clinically driven revascularization.

Comparison of resolute zotarolimus-eluting stents and sirolimus-eluting stents in patients with de novo long coronary artery lesions: a randomized LONG-DES IV trial

BACKGROUND

Procedural and clinical outcomes still remain unfavorable for patients with long coronary lesions who undergo stent-based coronary interventions. Therefore, we compared the relative efficacy and safety of resolute zotarolimus-eluting stents (R-ZES) and sirolimus-eluting stents (SES) for patients with de novo long coronary lesions.

METHODS AND RESULTS

This randomized, multicenter, prospective trial, called the Percutaneous Treatment of LONG Native Coronary Lesions With Drug-Eluting Stent-IV (LONG-DES IV) trial, compared long R-ZES and SES in 500 patients with long (≥25 mm) native coronary lesions. The primary end point of the trial was in-segment late luminal loss at 9-month angiographic follow-up. The baseline characteristics were not different between R-ZES and SES groups, including lesion lengths (32.4±13.5 mm versus 31.0±13.5 mm, P=0.27). At 9-month angiographic follow-up, the R-ZES was noninferior to the SES with respect to in-segment late luminal loss, the primary study end point (0.14±0.38 mm versus 0.12±0.43 mm, P for noninferiority=0.03, P for superiority=0.68). In addition, in-stent late luminal loss (0.26±0.36 mm versus 0.24±0.42 mm, P=0.78) and the rates of in-segment (5.2% versus 7.2%, P=0.44) and in-stent (4.0% versus 6.0%, P=0.41) binary restenosis were not significantly different between the 2 groups. There were no significant between-group differences in the rate of adverse clinical events (death, myocardial infarction, stent thrombosis, target-lesion revascularization, and composite outcomes).

CONCLUSIONS

For patients with de novo long coronary artery disease, R-ZES implantation showed noninferior angiographic outcomes as compared with SES implantation.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01186094.

Comparison of zotarolimus-eluting and sirolimus-eluting coronary stents: a study from the Western Denmark Heart Registry

Background

We evaluated the effectiveness and safety of a zotarolimus-eluting (ZES) versus a sirolimus-eluting (SES) coronary stent in a large cohort of patients treated with one of these stents in Western Denmark.

Methods

A total of 6,122 patients treated with ZES (n=2,282) or SES (n=3,840) were followed for up to 27 months. We ascertained clinical outcomes based on national medical databases.

Results

Incidence of target lesion revascularization (no. per 100 person-years) was 5.3 in the ZES group compared to 1.9 in the SES group (adjusted hazard ratio (HR)=2.19, 95% confidence intervals (CI): 1.39-3.47; p=0.001). All-cause mortality was also higher in the ZES group (ZES: 6.3; SES: 3.3; adjusted HR=1.34, 95% CI: 1.05-1.72; p=0.02), while stent thrombosis (ZES: 1.2; SES: 0.5; adjusted HR=1.98, 95% CI: 0.75-5.23; p=0.14) did not differ significantly.

Conclusions

In agreement with previously published randomised data, this observational study indicated that the ZES was associated with an increased risk of death and TLR in a large cohort of consecutive patients.

Zotarolimus-eluting vs. sirolimus-eluting coronary stents in patients with and without acute coronary syndromes: a SORT OUT III substudy

OBJECTIVES

To compare clinical outcomes among patients with acute coronary syndrome treated with zotarolimus-eluting and sirolimus-eluting stents in the SORT OUT III trial.

BACKGROUND

Currently, only limited data allow direct comparison of clinical outcomes among patients with acute coronary syndrome treated with a second-generation drug-eluting stent (DES) eluting zotarolimus vs. a first-generation DES eluting sirolimus.

METHODS

Patients with acute coronary syndrome (n=1052) were randomized to treatment with zotarolimus-eluting (n=506) or sirolimus-eluting (n=546) stents and followed for 18 months. The primary composite endpoint, major adverse cardiac events (MACE), was defined as a composite of cardiac death, myocardial infarction or target vessel revascularization.

RESULTS

Zotarolimus-eluting stent treatment compared to sirolimus-eluting stent treatment was associated with increased rates of MACE (8·7% vs. 5·0%; hazard ratio (HR), 1·78; 95% confidence interval (CI), 1·10-2·88; P=0·02) and TVR (6·8% vs. 3·9%; HR, 1·77; 95% CI, 1·03-3·04; P=0·04), while all-cause death, cardiac death, myocardial infarction and definite stent thrombosis did not differ significantly. In the same trial, stable angina pectoris patients (n=1206) were randomized to zotarolimus-eluting (n=614) and sirolimus-eluting (n=592) stents with similar results.

CONCLUSIONS

With and without acute coronary syndromes, patients treated with the sirolimus-eluting stent had better clinical outcomes than those treated with the zotarolimus-eluting stent.

Cost-effectiveness of everolimus- versus paclitaxel-eluting stents for patients undergoing percutaneous coronary revascularization (from the SPIRIT-IV Trial)

Although several drug-eluting stents (DESs) have been shown to be economically attractive compared to bare-metal stents in patients at moderate to high risk of restenosis, little is known about the cost-effectiveness of alternative DES designs, especially second-generation DESs. We therefore performed an economic substudy alongside the SPIRIT-IV trial, in which 3,687 patients undergoing single or multivessel percutaneous coronary intervention were randomized to receive second-generation everolimus-eluting stents (EESs; n = 2,458) or first-generation paclitaxel-eluting stents (PESs; n = 1,229). Costs through 2 years of follow-up were assessed from the perspective of the United States health care system. The primary cost-effectiveness end point was the incremental cost-effectiveness ratio assessed as cost per quality-adjusted life year gained. Over a 2-year period, use of EESs versus PESs led to a trend toward decreased overall repeat revascularization procedures (14.2 vs 16.2 per 100 subjects, p = 0.20) driven by a significant decrease in the number of target vessel revascularization procedures (8.2 vs 11.0 per 100 subjects, p = 0.02) but also a slight increase in the number of nontarget vessel revascularization procedures (6.0 vs 5.1 per 100 subjects, p = 0.37). Follow-up cardiovascular costs were decreased by $273/patient in the EES group (95% confidence interval for difference 1,048 less to 502 more, p = 0.49). Formal cost-effectiveness analysis based on these results demonstrated that the probability that EES was an economically attractive strategy (incremental cost-effectiveness ratio <$50,000/quality-adjusted life year gained) was 85.7%. These findings demonstrate that in patients undergoing percutaneous coronary intervention with DESs, use of EESs is economically attractive compared to PESs with improved clinical outcomes and lower overall medical care costs at 2 years.

Everolimus-eluting stents in interventional cardiology

Bare metal stents have a proven safety record, but limited long-term efficacy due to in-stent restenosis. First-generation drug-eluting stents successfully countered the restenosis rate, but were hampered by concerns about their long-term safety. Second generation drug-eluting stents have combined the low restenosis rate of the first generation with improved long-term safety. We review the evolution of drug-eluting stents with a focus on the safety, efficacy, and unique characteristics of everolimus-eluting stents.

Efficacy and safety of zotarolimus-eluting stents compared with sirolimus-eluting stents in patients undergoing percutaneous coronary interventions--a meta-analysis of randomized controlled trials

BACKGROUND

Whether ZES can further improve angiographic and clinical outcomes compared to SES still remains uncertain.

OBJECTIVES

The aim of this study was to assess the efficacy and safety of zotarolimus-eluting stents (ZES) compared with sirolimus-eluting stents (SES) in patients undergoing percutaneous coronary interventions (PCI).

METHODS

Major electronic information sources were explored for randomized controlled trials comparing ZES with SES among patients undergoing PCI during at least 9 months follow-up. The primary efficacy outcomes were target lesion revascularization (TLR), target vessel revascularization (TVR), and major adverse cardiac events (MACE); safety outcomes were stent thrombosis (ST), myocardial infarction (MI), and cardiac death.

RESULTS

Seven comparative studies were identified (a total of 5983 patients). When compared with ZES at 12-month follow-up, SES significantly reduced risk of MACE (relative risk [RR]: 0.74, 95% confidence interval [CI]: 0.61 to 0.89, p=0.002), and TLR (RR:0.39; 95% CI: 0.29 to 0.52; p<0.00001), without significant differences in terms of TVR (RR:0.68, 95% CI: 0.38 to 1.20; p=0.18), ST (RR:0.71; 95% CI: 0.39 to 1.31; p=0.28), cardiac death (RR:0.83; 95% CI: 0.49-1.42, p=0.50) or MI (RR:1.08; 95%CI: 0.80 to 1.45; p=0.62).

CONCLUSIONS

At 12-month follow-up, SES are superior to ZES in reducing the incidences of TLR and MACE in patients undergoing PCI, without significant differences in terms of TVR, ST, cardiac death, and MI.

Outcomes After Unrestricted Use of Everolimus-Eluting and Sirolimus-Eluting Stents in Routine Clinical Practice

Background—

It remains unclear whether there are differences in the safety and efficacy outcomes between everolimus-eluting stents (EES) and sirolimus-eluting stents (SES) in contemporary practice.

Methods and Results—

We prospectively enrolled 6166 consecutive patients who received EES (3081 patients) and SES (3085 patients) between April 2008 and June 2010, using data from the Interventional Cardiology Research In-Cooperation Society-Drug-Eluting Stents Registry. The primary end point was a composite of death, nonfatal myocardial infarction (MI), or target-vessel revascularization (TVR). At 2 years of follow-up, the 2 study groups did not differ significantly in crude risk of the primary end point (12.1% for EES versus 12.4% for SES; HR, 0.97; 95% CI, 0.84–1.12, P =0.66). After adjustment for differences in baseline risk factors, the adjusted risk for the primary end point remained similar for the 2 stent types (HR, 0.96; 95% CI, 0.82–1.12, P =0.60). There were also no differences between the stent groups in the adjusted risks of the individual component of death (HR, 0.93; 95% CI, 0.67–1.30, P =0.68), MI (HR, 0.97; 95% CI, 0.79–1.18, P =0.74), and TVR (HR, 1.10; 95% CI, 0.82–1.49, P =0.51). The adjusted risk of stent thrombosis also was similar (HR, 1.16; 95% CI, 0.47–2.84, P =0.75).

Conclusions—

In contemporary practice of percutaneous coronary intervention procedures, the unrestricted use of EES and SES showed similar rates of safety and efficacy outcomes with regard to death, MI, sent thrombosis, and TVR. Future longer-term follow-up is needed to better define the relative benefits of these drug-eluting stents.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01070420.

Short- and long-term outcomes with drug-eluting and bare-metal coronary stents: a mixed-treatment comparison analysis of 117 762 patient-years of follow-up from randomized trials

BACKGROUND

Drug-eluting stents (DES) have been in clinical use for nearly a decade; however, the relative short- and long-term efficacy and safety of DES compared with bare-metal stents (BMS) and among the DES types are less well defined.

METHODS AND RESULTS

PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials, until March 2012, that compared any of the Food and Drug Administration-approved durable stent and polymer DES (sirolimus-eluting stent [SES], paclitaxel-eluting stent [PES], everolimus-eluting stent [EES], zotarolimus-eluting stent [ZES], and ZES-Resolute [ZES-R]) with each other or against BMS for de novo coronary lesions, enrolling at least 100 patients and with follow-up of at least 6 months. Short-term (≤ 1 year) and long-term efficacy (target-vessel revascularization, target-lesion revascularization) and safety (death, myocardial infarction, stent thrombosis) outcomes were evaluated and trial-level data pooled by both mixed-treatment comparison and direct comparison analyses. From 76 randomized clinical trials with 117 762 patient-years of follow-up, compared with BMS, each DES reduced long-term target-vessel revascularization (39%-61%), but the magnitude varied by DES type (EES~SES~ZES-R>PES~ZES>BMS), with a >42% probability that EES had the lowest target-vessel revascularization rate. There was no increase in the risk of any long-term safety outcomes, including stent thrombosis, with any DES (versus BMS). In addition, there was reduction in myocardial infarction (all DES except PES versus BMS) and stent thrombosis (with EES versus BMS: Rate ratio, 0.51; 95% credibility interval, 0.35-0.73). The safest DES appeared to be EES (>86% probability), with reduction in myocardial infarction and stent thrombosis compared with BMS. Short-term outcomes were similar to long-term outcomes, with SES, ZES-R, and everolimus-eluting stent being the most efficacious and EES being the safest stent.

CONCLUSIONS

DES are highly efficacious at reducing the risk of target-vessel revascularization without an increase in any safety outcomes, including stent thrombosis. However, among the DES types, there were considerable differences, such that EES, SES, and ZES-R were the most efficacious and EES was the safest stent.

Intra-individual head-to-head comparison of Sirolimus®- and Paclitaxel®-eluting stents for coronary revascularization. A randomized, multi-center trial

BACKGROUND

Despite the known effects of drug-eluting stents (DES), other cofactors attributed to patient characteristics affect their success. Interest focused on designing a study minimizing these factors to answer continuing concerns on the heterogeneity of response to different DESs. The study's aim was to investigate the feasibility and impact of an intra-individual comparison design in patients (pts) with two coronary artery stenosis treated with a Sirolimus- (SES) and a Paclitaxel- (PES) eluting stent.

METHODS AND RESULTS

The study was conducted as a prospective, randomized, multi-center trial in 112 pts who consented to treatment with a SES and a PES. Pts were eligible if they suffered from the presence of two single primary target lesions in two different native coronary arteries. Lesions were randomized to either SES or PES treatment. The primary endpoint was in-stent luminal late loss (LLL), as determined by quantitative angiography at 8 months; clinical follow up was obtained at 1, 8, and 12 months additionally. The LLL (0.13 ± 0.28 mm SES vs. 0.26 ± 0.35 mm PES, p=0.011) showed less neointima in SES. With a predefined cut-off criterion of 0.2mm difference in LLL, 53/87 pts SES and PES were similar effective. 34/87 pts had a divergent result, 26 pts had greater benefit from SES while 8 pts had greater benefit from PES. Overall, MACE (MI, TLR, and death) occurred in 19 (17%) pts. Based on lesion analysis of 108 lesions treated with SES and 110 lesions treated with PES, 5 (4.6%) lesions with SES and 3 (2.7%) lesions with PES required repeated TLR.

CONCLUSION

An intra-individual comparison design to assess differences in efficacy of different DESs is feasible, safe and achieves similar results to inter-individual studies. This study is among the first to show that failure of one DES does not necessarily implicate failure of another DES and vice versa.

DUrable polymer-based sTent CHallenge of Promus ElemEnt versus ReSolute integrity (DUTCH PEERS): rationale and study design of a randomized multicenter trial in a Dutch all-comers population

BACKGROUND

Drug-eluting stents (DES) are increasingly used for the treatment of coronary artery disease. An optimized DES performance is desirable to successfully treat various challenging coronary lesions in a broad population of patients. In response to this demand, third-generation DES with an improved deliverability were developed. Promus Element (Boston Scientific, Natick, MA) and Resolute Integrity (Medtronic Vascular, Santa Rosa, CA) are 2 novel third-generation DES for which limited clinical data are available. Accordingly, we designed the current multicenter study to investigate in an all-comers population whether the clinical outcome is similar after stenting with Promus Element versus Resolute Integrity.

METHODS

DUTCH PEERS is a multicenter, prospective, single-blinded, randomized trial in a Dutch all-comers population. Patients with all clinical syndromes who require percutaneous coronary interventions with DES implantation are eligible. In these patients, the type of DES implanted will be randomized in a 1:1 ratio between Resolute Integrity versus Promus Element. The trial is powered based on a noninferiority hypothesis. For each stent arm, 894 patients will be enrolled, resulting in a total study population of 1,788 patients. The primary end point is the incidence of target vessel failure at 1-year follow-up.

SUMMARY

DUTCH PEERS is the first randomized multicenter trial with a head-to-head comparison of Promus Element and Resolute Integrity to investigate the safety and efficacy of these third-generation DES.

Long-term luminal change after drug-eluting stent implantation: serial angiographic follow-up study of the ZEST randomized trial

OBJECTIVE

To evaluate long-term patterns of luminal changes after implantation of different types of drug-eluting stents (DES), we analyzed the serial angiographic outcomes of patients implanted with zotarolimus-eluting stents (ZES), sirolimus-eluting stents (SES), or paclitaxel-eluting stents (PES).

BACKGROUND

Little is known regarding long-term luminal changes after DES implantation.

METHODS

As a subgroup analysis of the ZEST trial, we performed complete angiographic evaluation immediately after the procedure and at 9 months and 2 years in 111 patients with 165 lesions (36 patients with ZES, 40 with SES, and 35 with PES).

RESULTS

Baseline clinical, angiographic, and procedural characteristics were similar among the three groups. Quantitative angiographic analysis revealed significant decreases in minimal luminal diameter 9 months after stent implantation in the ZES (from 2.71 ± 0.49 to 2.21 ± 0.42 mm, P < 0.001), SES (from 2.79 ± 0.49 to 2.58 ± 0.57 mm, P < 0.001), and PES (from 2.66 ± 0.45 to 2.19 ± 0.52 mm, P < 0.001) groups. However, significant late improvements with different degree in luminal diameter were observed between 9 months and 2 years in the ZES (from 2.21 ± 0.42 to 2.39 ± 0.58 mm, P = 0.001), SES (from 2.58 ± 0.57 to 2.66 ± 0.60 mm, P = 0.039), and PES (from 2.19 ± 0.52 to 2.43 ± 0.52 mm, P < 0.001) groups.

CONCLUSION

Serial angiographic follow-up study revealed a biphasic luminal response after DES implantation, characterized by an early progression phase for the first 9 months and a late regression phase from 9 months to 2 years.

Stent thrombosis: incidence, predictors and new technologies

Some concerns have been raised regarding the risk of late and very late stent thrombosis (ST) following drug-eluting stent implantation. Despite remaining an uncommon complication of percutaneous coronary intervention, when ST occurs, it can be catastrophic to the individual, commonly presenting as acute ST elevation myocardial infarction or sudden cardiac death. The incidence and predictors of ST have been reported in the literature and the role of dual antiplatelet therapies in the avoidance of such a complication remains vital. Ongoing studies are assessing the role of these therapies including platelet reactivity testing, genetic testing and optimum duration of therapy. In addition, newer polymer-free and bioabsorbable stents are under investigation in the quest to potentially minimise the risk of ST.