Outcomes associated with drug-eluting and bare-metal stents: a collaborative network meta-analysis

Three-year clinical outcome after primary stenting of totally occluded native coronary arteries: a randomized comparison of bare-metal stent implantation with sirolimus-eluting stent implantation for the treatment of total coronary occlusions (Primary Stenting of Totally Occluded Native Coronary Arteries [PRISON] II study)

BACKGROUND

The purpose of this study was to examine the 3-year clinical outcome in patients enrolled in the Primary Stenting of Totally Occluded Native Coronary Arteries II study.

METHODS

Patients with totally occluded coronary arteries randomized to either sirolimus-eluting Cypher stents (SESs) (Cordis, a Johnson & Joshson Company, Miami Lakes, FL) (100 patients) or bare-metal BxVelocity stents (BMSs) (Cordis) (100 patients) were followed clinically for 3 years.

RESULTS

Between 1 and 3 years, there were infrequent additional clinical events that were equally distributed between the SES and the BMS group. After 3 years, target lesion revascularization was 7% in the SES group versus 27% in the BMS group (P < .001); and target vessel revascularization was seen in 11% in the SES group versus 30% in the BMS group (P = .002). Major adverse cardiac events were noted in 10% of the SES group versus 34% in the BMS group (P < .001). There were no statistically significant differences in death, myocardial infarction, and stent thrombosis according to the Academic Research Consortium criteria between the 2 groups.

CONCLUSIONS

Clinical outcome up to 3 years after implantation of SESs for total coronary occlusions continues to demonstrate a significant reduction in adverse clinical events compared with BMSs without the evidence for either disproportionate late restenosis or late stent thrombosis.

Choice of DES: is there a difference?

Restenosis after percutaneous coronary interventions has been a major limitation of this otherwise very well-accepted method of coronary revascularisation. Coronary stents work by scaffolding the intimal flaps and preventing elastic recoil, which was a major problem after balloon angioplasty. The neointimal growth response to stenting contributes significantly to the restenotic process. Randomised studies comparing coronary artery bypass surgery with coronary stenting especially in multivessel disease clearly highlighted this problem. The problem has been greater in magnitude in special subgroups: diabetics, patients with small vessels (≤2.5 mm in diameter), long segments of disease (≥20 mm in length), etc. These limitations of Bare metal stents have been addressed by drug-eluting stents (DESs). Third-generation stents with bioabsorbable polymers like the Biolimus releasing Biomatrix stent have already become available in Europe and parts of Asia. A longer follow-up will prove their long-term safety vis-à-vis first-generation DES. The polymer-free stent with capability of using more than one drug, though very attractive, needs larger multicentric studies before gaining wider acceptance. The fully bioabsorbable stent is yet another promising concept. The feasibility has already been demonstrated, and finer refinements are under way. The future of newer DES thus is very promising, and most of the issues related to first-generation DES are at the threshold of being solved.

Cost effectiveness of drug-eluting stents in Belgian practice: healthcare payer perspective

BACKGROUND

There has been a steep increase in the number of percutaneous coronary intervention procedures performed for coronary heart disease since their introduction about 30 years ago. Recently, the use of drug-eluting stents (DES) compared with the original bare metal stents (BMS) has increased in many countries.

OBJECTIVE

To assess the cost effectiveness of DES versus BMS in a real-world setting from the Belgian healthcare payer perspective.

METHODS

We developed a decision analysis model to estimate incremental costs (year 2004 or 2007 values [depending on the underlying variable]) and effectiveness. Incremental effectiveness was calculated by combining relative benefits from published meta-analyses with real-world observations from a Belgian registry. Probabilistic modelling and sensitivity analyses were performed. The model had a 1-year time horizon. Sixteen sub groups were created based on the following characteristics: initial stent type, diabetic status, complex lesion and multi-vessel disease. Scenario analyses were performed for the influence on reinterventions and the duration of clopidogrel use. In each analysis, 1000 Monte Carlo simulations were performed.

RESULTS

The incremental costs for switching from BMS to DES are substantial (approximately euro1000), while the benefits, expressed as QALYs, are extremely small (on average <0.001 QALYs gained). This led to very high incremental cost-effectiveness ratios: over euro860 000 per QALY gained in all subgroups and scenario analyses.

CONCLUSION

Comparing DES with BMS, no life-years are gained and small quality-of-life improvements are achieved for short periods, resulting in a high likelihood that DES are not cost effective. When there is competition for scarce resources this should be considered when deciding on the reimbursement of this technology.

Neurological complications of cardiac surgery

Neurological injury resulting from cardiac surgery has a range of manifestations from focal neurological deficit to encephalopathy or coma. As the safety of drug-eluting stents comes into question, more patients will likely undergo coronary artery bypass graft surgery. These projections, along with the growing proportions of elderly patients and those with comorbidities, portend the potential for rising rates of perioperative neurological complications. The risk for neurological injury may be determined by the type of procedure, by patient-specific characteristics, and by the extent of cerebral embolization and hypoperfusion during and after surgery. Changes in surgical techniques, including the use of off-pump surgery, have not decreased rates of brain injury from cardiac surgery. When appropriate, modern neuroimaging techniques should be used in postoperative patients to confirm diagnosis, to provide information on potential etiology, to direct appropriate therapy, and to help in prognostication. Management of postoperative medications and early use of rehabilitation services is a recommended strategy to optimize the recovery for individuals with neurological injury after cardiac surgery.

Off-label use of stents: bare-metal versus drug-eluting stents

Drug-eluting stents (DES) became the default strategy for percutaneous revascularization due to their improved intermediate-term outcomes when compared with bare-metal stents (BMS) in the pivotal randomized, controlled trials. The excellent results of DES in on-label or US FDA-approved indications led to extrapolation of the results to more complex situations that were excluded from initial pivotal trials; such as off-label indications. Safety concerns began to grow after reports of increased late thrombosis and possibly associated increased death and myocardial infarction with DES, especially in the off-label situations. Recently, however, several important published registries have calmed some of those uncertainties and reassured the cardiology community of the safety and efficacy of DES compared with BMS. There is an overall poorer outcome with off-label use of any stent (BMS or DES) compared with standard or on-label use. This difference in outcome is most likely related to patient or specific coronary lesion characteristics or comorbidities that predispose an individual to adverse outcomes regardless of the stent type used. It is accepted now that DES use does result in a small increased risk of late thrombosis, but that risk is offset by a significant reduction in restenosis. Overall, the current data suggest that the use of DES in most lesion subsets is at least as safe as and clearly more efficacious than use of BMS in similar situations.

Safety and efficacy update on first-generation drug-eluting stents

Accumulating data on the safety and efficacy of first-generation drug-eluting stents (DES) show a favorable risk/benefit profile compared with bare-metal stents (BMS). A recently reported collaborative network meta-analysis including >18,000 patients in 38 randomized trials along with other recent meta-analyses indicate that the use of DES versus BMS is associated with a 50%-70% reduction in the need for repeat revascularization and no difference in the rates of overall stent thrombosis, overall mortality, cardiac mortality, or death or myocardial infarction over 4 years of follow-up. Furthermore, the most recent data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) indicate no difference in mortality between DES and BMS use. The collaborative network meta-analysis and other analyses suggest that late stent thrombosis is a distinct but infrequent phenomenon complicating the use of DES; the risk posed by late thrombosis appears to be offset by a reduced need for repeat revascularizations and thus, a reduced risk of adverse outcomes associated with such interventions.

The question of drug-eluting stent safety: then and now

A well-publicized presentation at the 2006 meeting of the World Congress of Cardiology (WCC) raised questions about the safety of drug-eluting stents (DES), leading to a rapid change in clinical practices for patients undergoing percutaneous coronary interventions. Subsequent independent analyses, which included patient-level data, found that DES, despite a small risk of very late stent thrombosis, are as safe as bare-metal stents and substantially reduce the risk of repeat revascularization. This article presents possible reasons for the differences between the conclusions of the 2006 WCC presentation and those of subsequent studies, and presents data that have emerged since the WCC 2006 meeting regarding the safety of DES.

Prognostic significance of myocardial ischemia by dobutamine stress echocardiography in patients without angina pectoris after coronary revascularization

The clinical utility of stress testing in patients without angina pectoris after revascularization has been questioned. Dobutamine stress echocardiography (DSE) is an established technique for detection of myocardial ischemia and cardiac risk stratification. We studied the prognostic value of DSE in 393 patients without typical angina pectoris after coronary revascularization. Ischemia was incremental to clinical data in predicting all-cause death (hazard ratio 3.5, 95% confidence interval 1.8 to 6.7) and cardiac death (hazard ratio 4.2, 95% confidence interval 1.8 to 9.8). In conclusion, myocardial ischemia during DSE is independently associated with an increased risk of all-cause mortality and cardiac death in these patients after adjustment for clinical data.

Safety of drug-coated stents

BACKGROUND

Drug-coated (i.e., drug-eluting) stents (DES) are frequently used nowadays in the treatment of coronary artery disease given their superior antirestenotic effect and clear benefits in terms of reduction of repeat revascularizations and major adverse cardiac events. However, a number of safety concerns have been raised on DES.

OBJECTIVE

To appraise current data on the safety of DES.

METHODS

A thorough PubMed search was done for pertinent clinical reports on DES safety with the following string (updated December 2007): (drug(*) OR sirolimus OR paclitaxel) AND eluting(*) AND stent(*) AND (safety OR complication(*) OR thrombos(*) OR infarction) NOT (editorial[pt] OR review[pt]).

RESULTS/CONCLUSION

A total of 1077 citations were retrieved and appraised. The most relevant threats to DES safety were bleeding, difficulties in balloon deflation and retrieval, endothelial dysfunction and vasospasm, hypersensitivity, infection, late acquired malapposition and aneurysm formation, late restenosis, peri-procedural myocardial infarction, plaque prolapse, stent dislodgement or embolization, stent fracture, and stent thrombosis (with ensuing risk of death, myocardial infarction or arrhythmia). Of these, the most important and debated safety issue is the potentially increased risk in late stent thrombosis, which might offset the antirestenotic benefits of DES especially in patients at higher risk of thrombosis or who cannot comply with the recommended dual antiplatelet regimen. Nonetheless, further clinical studies are warranted to clarify whether these safety threats should be a concern for the large target population of patients with coronary artery disease most likely to benefit from DES implantation.

Incidence and correlates of drug-eluting stent thrombosis in routine clinical practice. 4-year results from a large 2-institutional cohort study

OBJECTIVES

We sought to determine the risk of late stent thrombosis (ST) during long-term follow-up beyond 3 years, searched for predictors, and assessed the impact of ST on overall mortality.

BACKGROUND

Late ST was reported to occur at an annual rate of 0.6% up to 3 years after drug-eluting stent (DES) implantation.

METHODS

A total of 8,146 patients underwent percutaneous coronary intervention with a sirolimus-eluting stent (SES) (n=3,823) or paclitaxel-eluting stent (PES) (n=4,323) and were followed up to 4 years after stent implantation. Dual antiplatelet treatment was prescribed for 6 to 12 months.

RESULTS

Definite ST occurred in 192 of 8,146 patients with an incidence density of 1.0/100 patient-years and a cumulative incidence of 3.3% at 4 years. The hazard of ST continued at a steady rate of 0.53% (95% confidence interval [CI]: 0.44 to 0.64) between 30 days and 4 years. Diabetes was an independent predictor of early ST (hazard ratio [HR]: 1.96; 95% CI: 1.18 to 3.28), and acute coronary syndrome (HR: 2.21; 95% CI: 1.39 to 3.51), younger age (HR: 0.97; 95% CI: 0.95 to 0.99), and use of PES (HR: 1.67; 95% CI: 1.08 to 2.56) were independent predictors of late ST. Rates of death and myocardial infarction at 4 years were 10.6% and 4.6%, respectively.

CONCLUSIONS

Late ST occurs steadily at an annual rate of 0.4% to 0.6% for up to 4 years. Diabetes is an independent predictor of early ST, whereas acute coronary syndrome, younger age, and PES implantation are associated with late ST.

Long-term clinical outcomes after drug-eluting and bare-metal stenting in Massachusetts

BACKGROUND

Drug-eluting stents (DES) reduce the need for repeat revascularization, but their long-term safety relative to that of bare-metal stents (BMS) in general use remains uncertain. We sought to compare the clinical outcome of patients treated with DES with that of BMS.

METHODS AND RESULTS

All adults undergoing percutaneous coronary intervention with stenting between April 1, 2003, and September 30, 2004, at non-US government hospitals in Massachusetts were identified from a mandatory state database. Patients were classified from the index admission according to stent types used. Clinical and procedural risk factors were collected prospectively. Risk-adjusted mortality, myocardial infarction, and revascularization rate differences (DES-BMS) were estimated through propensity score matching without replacement. A total of 11 556 patients were treated with DES, and 6237 were treated with BMS, with unadjusted 2-year mortality rates of 7.0% and 12.6%, respectively (P<0.0001). In 5549 DES patients matched to 5549 BMS patients, 2-year risk-adjusted mortality rates were 9.8% and 12.0%, respectively (P=0.0002), whereas the respective rates for myocardial infarction and target-vessel revascularization were 8.3% versus 10.3% (P=0.0005) and 11.0% versus 16.8% (P<0.0001).

CONCLUSIONS

DES treatment was associated with lower rates of mortality, myocardial infarction, and target-vessel revascularization than BMS treatment in similar patients in a matched population-based study. Comprehensive follow-up in this inclusive population is warranted to identify whether similar safety and efficacy remain beyond 2 years.

Biolimus-eluting stent with biodegradable polymer versus sirolimus-eluting stent with durable polymer for coronary revascularisation (LEADERS): a randomised non-inferiority trial

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.

Long-term impact of drug-eluting stents versus bare-metal stents on all-cause mortality

OBJECTIVES

Our purpose was to examine the incidence of all-cause mortality among drug-eluting stents (DES) and bare-metal stents (BMS) while adjusting for many confounding factors generally not considered in prior studies.

BACKGROUND

DES use in the U.S. declined by up to 50% in recent years, primarily due to concerns about late stent thrombosis and possibly increased mortality. However, recent data suggest that DES are as safe as BMS and may actually be associated with a lower incidence of myocardial infarction and mortality.

METHODS

All patients undergoing percutaneous coronary intervention with a DES or BMS alone from March 1, 2003, to June 30, 2007, at a tertiary care center were assessed. Multivariable Cox proportional hazards modeling was performed for overall and propensity-matched patients. Socioeconomic status was calculated using U.S. Census 2000 data. The primary end point was all-cause mortality.

RESULTS

There were a total of 832 deaths over a 4.5-year interval among 8,032 patients. Of these, 6,053 received a DES and 1,983 patients had a BMS. All-cause mortality was significantly lower in unadjusted and adjusted Cox proportional models with DES (hazard ratio: 0.62, 95% confidence interval: 0.53 to 0.73; p < 0.001). Similarly, in the propensity-matched group, DES remained associated with lower mortality compared with BMS (adjusted hazard ratio: 0.54, 95% confidence interval: 0.45 to 0.66; p < 0.001).

CONCLUSIONS

DES were associated with lower mortality in this "real-world" setting. However, despite multiple adjustments, potential confounding may still play a role.

Drug-eluting stent thrombosis

Stent thrombosis is a rare complication following stent implantation; if it occurs, however, it is associated with a high morbidity and mortality. Despite reduced rates of restenosis, drug-eluting stents (DES) have not reduced the incidence of stent thrombosis as compared with bare-metal stents (BMS). Patient-, lesion-, and procedure-related factors as well as thrombogenicity of the stent itself are involved in the pathogenesis of stent thrombosis. Furthermore, early cessation of dual antiplatelet therapy correlates with an increased risk of stent thrombosis. This review focuses on clinical evidence and pathophysiological mechanisms of stent thrombosis with DES, particularly highlighting prothrombotic effects of the stent itself.

Drug eluting and bare metal stents in people with and without diabetes: collaborative network meta-analysis

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.

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

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.

Low-dose paclitaxel elution by novel bioerodible sol-gel coating on stents inhibits neointima with low toxicity in porcine coronary arteries

OBJECTIVES

The present study was designed to evaluate a novel bioerodible sol-gel film coated paclitaxel-eluting stent (sol-gel-PES, 3 microg per stent) in a porcine coronary artery model.

BACKGROUND

Although current polymer-based PES decrease restenosis, the permanent polymer and bound drug have raised concerns regarding delayed vessel healing and late stent thrombosis.

METHODS

Polymer-based PES (poly-PES, n = 8), sol-gel-PES (n = 15), bare metal (BMS, n = 14), and sol-gel film only (sham, n = 12), stents were implanted in 17 juvenile pigs. Animals were terminated 28 days post-implant for angiographic restudy and complete histopathologic and histomorphometric analyses.

RESULTS

Angiographic late loss was equally reduced for both poly-PES and sol-gel-PES (0.51 +/- 0.64 and 0.61 +/- 0.52 mm, respectively) compared to both BMS and sham (0.98 +/- 0.74 and 1.25 +/- 0.72 mm, p < 0.05). Similarly beneficial results were observed for histomorphometric parameters of neointimal thickness and area, yielding reductions of in-stent stenosis by 43% and 48% for poly-PES, as well as 31% and 37% for sol-gel-PES, vs. BMS and sham, respectively (p < 0.05). Re-endothelialization was complete in all groups. Although the inflammatory cell infiltration and intramural thrombus scores were no different between poly- and sol-gel-PES, medial necrosis was increased for poly-PES (p < 0.05 vs. all others).

CONCLUSIONS

A novel bioerodible sol-gel film coated with low-dose paclitaxel demonstrates less toxicity to the coronary tunica media, while retaining effective inhibition of neointimal formation at 28 days.

Drug-Eluting Stents Versus Bare-Metal Stents for Off-Label Indications

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.

Catheter-Based Treatment of Coronary Artery Disease

September 2007 marked the 30-year anniversary of the first human percutaneous coronary intervention, an index event that changed the course of modern-day cardiovascular care. Before that first procedure, adult invasive cardiology focused on diagnostic angiography as well as hemodynamic assessment of structural heart disease. Since that initial procedure, percutaneous coronary intervention has become the most frequently performed coronary revascularization procedure worldwide. Several factors have been responsible for this dramatic paradigm shift, the most prominent being identification of opportunities for technical improvement and the application of innovation and investigation in concert with colleagues, professional societies, and industry. These approaches will continue to be of paramount importance as new technologies are brought to bear on an increasingly broader group of patients with cardiovascular disease.

Observations and outcomes of definite and probable drug-eluting stent thrombosis seen at a single hospital in a four-year period

Stent thrombosis (ST) is a major safety concern after drug-eluting stent (DES) deployment, resulting in significant morbidity and mortality. The goal of this study was to examine the incidence, timing, clinical correlates, and outcomes after DES thrombosis in a real-world population. A retrospective analysis of 8,402 patients who underwent percutaneous coronary intervention and received a DES was performed. After DES implantation, 84 definite (DST) and 127 probable ST events occurred. The incidence of early DST was 0.8%, late DST was 0.4%, and very late DST was 0.4%. Multivariate analysis showed that a history of diabetes mellitus, myocardial infarction during admission, number of stents, and DES placement in a restenotic lesion were independently associated with DST. The incidence of early definite or probable ST (DPST) was 1.9%, late DPST was 1.4%, and very late DPST was 0.7%. Multivariate analysis showed that a history of diabetes, myocardial infarction during admission, cardiogenic shock, number of stents, and DES use in a restenotic lesion were independently associated with DPST. Both types of ST were associated with significantly higher rates of all-cause death, Q-wave myocardial infarction, and revascularization up to 24 months after DES implantation. In conclusion, ST after DES implantation in contemporary practice continues to occur from 30 days to 2 years at a rate > or =0.36%/year and is associated with high rates of morbidity and mortality. Diabetes mellitus, myocardial infarction, and DES use in a restenotic lesion were strongly associated with DST; therefore, careful consideration should apply when deploying a DES in these populations.