One-year clinical outcomes of patients treated with polymer-free amphilimus-eluting stents or zotarolimus-eluting stents: A propensity-score adjusted analysis

Individualizing Medicinal Therapy Post Heart Stent Implantation: Tailoring for Patient Factors

The field of cardiovascular medicine is undergoing a transformative shift towards personalized medicinal therapy, particularly in the context of post stent implantation. This narrative review explores the significance, challenges, and future directions of individualized treatment strategies for patients with coronary stents. The review highlights the pivotal role of personalized approaches in optimizing treatment efficacy and minimizing adverse events. Real-world clinical studies and trials underscore the importance of tailoring antiplatelet therapy based on platelet function testing, genetic testing, and risk scoring. These studies reveal that personalized medicinal treatment improves clinical outcomes by balancing preventing thrombotic events and mitigating bleeding risks. Challenges, including cost, test availability, patient adherence, and ethical considerations, are discussed in depth, shedding light on the complexities of implementing personalized approaches. Technological advancements, including omics data integration, artificial intelligence, and big data analytics, shape the future of personalized medicinal therapy. These tools enable precise pharmacogenomic selection of medications and the development of integrated risk-scoring systems. Patient engagement and education are also central, with empowered patients and remote monitoring contributing to collaborative decision-making. In conclusion, the narrative review underscores that personalized medicinal therapy post stent implantation holds immense promise for revolutionizing cardiovascular care. By embracing a comprehensive approach that considers genetics, clinical factors, and patient preferences, healthcare providers can optimize treatment outcomes and improve patient quality of life. The evolving landscape of personalized medicine offers a glimpse into a future where tailored treatment strategies become the cornerstone of precision cardiovascular care.

Clinical Outcomes of Polymer-Free Versus Polymer-Coated Drug-Eluting Stents in Patients With Coronary Artery Disease: A Systematic Review and Meta-Analysis

Drug-eluting stents have transformed the treatment of coronary artery disease (CAD), and there are two types: polymer-free and polymer-coated stents. Polymer-free stents have a coating that is quickly absorbed by the body, whereas polymer-coated stents have a coating that remains on the stent surface. This meta-analysis and systematic review aimed to compare the clinical outcomes of these two stent types in patients with coronary artery disease. The literature and abstracts from significant databases were reviewed to compare polymer-free drug-eluting stents (PF-DES) and polymer-coated drug-eluting stents (PC-DES) for the treatment of coronary artery disease (CAD). The primary efficacy endpoints of the study were all-cause mortality and deaths from cardiovascular and non-cardiovascular causes. Among the secondary outcomes were incidences of myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), stent thrombosis, stroke, and major adverse cardiovascular events (MACEs). In terms of the primary outcomes, the combined analysis revealed a marginally lower risk of all-cause mortality (relative risk, RR (95% CI) = 0.92 (0.85, 1.00), p = 0.05, I² = 0%) with the use of PF-DES versus PC-DES. Nonetheless, there was no significant difference in cardiovascular mortality (RR (95% CI) = 0.97 (0.87, 1.08)) or non-cardiovascular mortality (RR (95% CI) = 0.87 (0.69, 1.10), p = 0.25, I² = 9%) between the groups. Furthermore, univariate meta-regression revealed that male gender and prior myocardial infarction were independently associated with an increased risk of all-cause mortality and cardiovascular disease. According to the current meta-analysis, no statistically significant differences existed in PF-DES and PC-DES outcomes. More extensive research is needed to investigate these findings further and establish their validity.

One-year outcomes of polymer-free amphilimus-eluting stents versus durable polymer zotarolimus-eluting stents in patients with diabetes mellitus: a meta-analysis

Background

Diabetes mellitus (DM) and cardiovascular diseases often co-exist. Today, percutaneous coronary intervention (PCI) is the preferred revascularization procedure for majority of patients with coronary artery disease. Polymer-free amphilimus-eluting stents (AES) represent a novel elution technology in the current era of drug-eluting stents. In this analysis, we aimed to systematically compare the cardiovascular outcomes which are associated with polymer-free amphilimus-eluting stents (AES) versus the durable polymer zotarolimus-eluting stents (ZES) for the treatment of patients with DM.

Methods

Http://www.ClinicalTrials.gov, EMBASE, Web of Science, MEDLINE, Cochrane database and Google Scholar were searched for publications comparing polymer-free AES versus durable polymer ZES in patients with DM. Selective cardiovascular outcomes were assessed. Statistical analysis was carried out by the latest version of the RevMan software. Risk ratio (RR) with 95% confidence interval (CI) was used to represent the data analysis.

Results

Four studies with a total number of 1795 participants with DM whereby 912 patients were assigned to be revascularized by the polymer-free AES and 883 patients were assigned to be revascularized by the durable polymer ZES were included in this analysis. In patients with DM, at one year, polymer-free AES were associated with significantly lower risk of major adverse cardiac events (MACEs) (RR: 0.69, 95% CI: 0.54–0.88; P = 0.002) and target lesion failure (TLF) (RR: 0.66, 95% CI: 0.48–0.91; P = 0.01) compared to durable polymer ZES. However, there was no significant change in all-cause mortality (RR: 0.79, 95% CI: 0.51–1.22; P = 0.28), cardiac death and the other cardiovascular outcomes. Similar risk of total stent thrombosis (RR: 1.13, 95% CI: 0.60–2.13; P = 0.70), including definite stent thrombosis (RR: 1.12, 95% CI: 0.38–3.31; P = 0.84), probable stent thrombosis (RR: 0.87, 95% CI: 0.37–2.09; P = 0.76), possible stent thrombosis (RR: 1.19, 95% CI: 0.50–2.87; P = 0.69) and late stent thrombosis (RR: 1.00, 95% CI: 0.17–5.72; P = 1.00) as between polymer-free AES and durable polymer ZES in patients with DM.

Conclusions

At 1 year follow-up, polymer-free AES were associated with significantly lower MACEs and TLF compared to durable polymer ZES in these patients with DM, without any increase in mortality, stent thrombosis and other cardiovascular outcomes. However, this analysis is only based on a follow-up time period of one year, therefore, future research should focus on the long term follow-up time period.

Safety and efficacy of the polymer-free and polymer-coated drug-eluting stents in patients undergoing percutaneous coronary intervention

INTRODUCTION

The relative safety and efficacy of polymer-free (PF) versus polymer-coated (PC) drug-eluting stents (DES) in patients with angina or acute coronary syndrome (ACS) undergoing percutaneous coronary intervention has received limited study.

METHOD

Digital databases were queried to identify relevant studies. Major adverse cardiovascular events (MACE) and secondary outcomes were compared using a random effect model to calculate unadjusted odds ratios (OR).

RESULTS

A total of 28 studies consisting of 23,198 patients were included in the final analysis. On pooled analysis, there was no significant difference in the odds of MACE (OR 0.98, 95% CI 0.91-1.08) and major bleeding (OR 0.87, 95% CI 0.61-1.24) between patients undergoing PF-DES versus PC-DES. Similarly, the odds of myocardial infarction, stroke, stent thrombosis, cardiovascular mortality and need for target vessel revascularization was similar between the two groups. PF-DES was favored due to significantly lower odds of non-cardiac death (OR 0.78, 95% CI 0.68-89) and all-cause mortality (OR 0.87, 95% CI 0.80-0.95), but had a higher need for target lesion revascularization (OR 1.2, 95% CI 1.02-1.42). A subgroup analysis based on follow up duration, clinical presentation, presence of diabetes and class of eluting drugs mirrored the net estimates for all outcomes with a few exceptions. A sensitivity and meta-regression analysis showed no influence of single-study and duration of antiplatelet therapy on pooled outcomes.

CONCLUSION

In patients presenting with angina or ACS, PF-DES might be favored due to lower all-cause mortality and equal risk of ischemic adverse cardiovascular and major bleeding events compared with PC-DES.

Direct comparison of predictive performance of PRECISE-DAPT versus PARIS versus CREDO-Kyoto: a subanalysis of the ReCre8 trial

Background

Multiple scores have been proposed to guide risk stratification after percutaneous coronary intervention. This study assessed the performance of the PRECISE-DAPT, PARIS and CREDO-Kyoto risk scores to predict post-discharge ischaemic or bleeding events.

Methods

A total of 1491 patients treated with latest-generation drug-eluting stent implantation were evaluated. Risk scores for post-discharge ischaemic or bleeding events were calculated and directly compared. Prognostic performance of both risk scores was assessed with calibration, Harrell’s c‑statistics net reclassification index and decision curve analyses.

Results

Post-discharge ischaemic events occurred in 56 patients (3.8%) and post-discharge bleeding events in 34 patients (2.3%) within the first year after the invasive procedure. C‑statistics for the PARIS ischaemic risk score was marginal (0.59, 95% confidence interval (CI) 0.51–0.68), whereas the CREDO-Kyoto ischaemic risk score was moderate (0.68, 95% CI 0.60–0.75). With regard to post-discharge bleeding events, CREDO-Kyoto displayed moderate discrimination (c-statistic 0.67, 95% CI 0.56–0.77), whereas PRECISE-DAPT (0.59, 95% CI 0.48–0.69) and PARIS (0.55, 95% CI 0.44–0.65) had a marginal discriminative capacity. Net reclassification index and decision curve analysis favoured CREDO-Kyoto-derived bleeding risk assessment.

Conclusion

In this contemporary all-comer population, PARIS and PRECISE-DAPT risk scores were not resilient to independent testing for post-discharge bleeding events. CREDO-Kyoto-derived risk stratification was associated with a moderate predictive capability for post-discharge ischaemic or bleeding events. Future studies are warranted to improve risk stratification with more focus on robustness and rigorous testing.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01486-y) contains supplementary material, which is available to authorized users.

Numerical analysis of paclitaxel-eluting coronary stents: Mechanics and drug release properties

Since theoretical models provide data that cannot be otherwise gathered, numerical methods applied to medical devices analysis have emerged as fundamental tool in preclinical development. Large efforts were done to study mechanical and drug-eluting properties in stents but often the coating modelling is neglected. This work presents a finite element framework to calculate mechanical loads and drug distribution in three commercial drug-eluting stents (Palmaz-Schatz, Palmaz Genesis and Multi Link Vision), to check coatings strength and drug distribution maps in biological tissues. The promising copolymer poly(methylmethacrylate-co-n-butylmethacrylate), loaded with paclitaxel, is analyzed. Results demonstrated that the coating undergoes localized plastic phenomena, and calculated stresses are lower than the ultimate stress, ensuring coating integrity. Computed drug concentration depends on stent geometry and its values are in all cases lower than the toxicity level for this drug.

The Cre8 amphilimus-eluting stent for the treatment of coronary artery disease: safety and efficacy profile

Introduction: Polymer-free drug-eluting stents are designed with stent surface modifications and drug-matrix formulations in order to release antiproliferative agents without the need of a polymer coating. Polymer-free technologies have the potential to overcome complications due to polymer persistence over time, such as local inflammatory reactions, delayed arterial healing, neoatherosclerosis, and subsequent ischemic adverse events.Areas covered: The Cre8 polymer-free amphilimus-eluting stent received CE mark in 2011 and was conceived with the aim of addressing the safety and efficacy limitations of early generation drug-eluting stents based on permanent polymer coatings. Besides the absence of polymer, the main features of the Cre8 stent include the abluminal reservoirs, the passive carbon film coating, and the antiproliferative agent formulation based on sirolimus mixed with free-fatty acid chain - namely amphilimus. This review will focus on the Cre8 development, technical characteristics, preclinical evidence, clinical efficacy and safety, and future perspectives.Expert opinion: The Cre8 stent has shown favorable angiographic and clinical outcomes at short and medium-term follow-up. This technology might provide a benefit in patients with diabetes. Further randomized evidence is required to provide an adequate clinical evaluation of this promising technology in patients with and without diabetes.

One-year clinical outcomes of patients treated with polymer-free amphilimus-eluting stents or zotarolimus-eluting stents: A propensity-score adjusted analysis

Background

Polymer‐free amphilimus‐eluting stents (PF‐AES) represent a novel elution‐technology in coronary stenting. We aimed to assess 1‐year clinical outcomes of PF‐AES as compared to latest‐generation permanent polymer zotarolimus‐eluting stents (PP‐ZES) in a real‐world all‐comers setting.

Methods

A prospective registry of patients treated with either PF‐AES or PP‐ZES between 2014 and 2016 was conducted. The primary outcome was defined as major adverse cardiac and cerebrovascular events (MACCE), and the secondary outcome was defined as target‐lesion failure (TLF) at 1 year. To account for measured confounders, a propensity‐score adjusted Cox proportional‐hazard model was built to evaluate clinical outcomes.

Results

A total of 734 consecutive patients with 1,269 DES implantations were enrolled. The population was characterized by 28% diabetes, 24% ST‐segment elevation myocardial infarction, and a high number of complex lesions (69%). The rate of MACCE was 11.5% for PF‐AES and 13.6% for PP‐ZES, p_log‐rank = 0.11. TLF was numerically lower in PF‐AES as compared to PP‐ZES (5.4 vs. 6.1%, p_log‐rank = 0.68). After propensity‐score adjustment, PF‐AES showed a trend toward a lower rate of MACCE and a favorable rate of TLF as compared to PP‐ZES (HR 0.70; 95%CI 0.45 to 1.10, P = 0.12; and HR 0.88; 95%CI 0.47 to 1.65, P = 0.68, respectively). Rates of definite ST were low (0.8 vs. 0.3%, p_log‐rank = 0.62).

Conclusions

Our study suggests that implantation of PF‐AES was safe and effective in real‐world patients, with low‐rates of MACCE and TLF at 1 year. Our data needs to be confirmed by a large trial to evaluate the clinical outcomes of this novel polymer‐free, eluting‐technology used in PF‐AES.