?Real life? use of sirolimus-eluting coronary stents in Germany

Coronary stenting with the sirolimus-eluting stent in patients with restenosis after intracoronary brachytherapy: results from the prospective multicentre German Cypher Stent Registry

BACKGROUND

Treatment of restenosis following intracoronary brachytherapy (ICB) is still a challenging problem. Implantation of sirolimus-eluting stents (SES) in this setting may be an option to be evaluated.

METHODS AND RESULTS

We analysed the prospective multicentre SES registry, the German Cypher Stent Registry. 7,445 patients treated with an SES during percutaneous coronary intervention (PCI) were registered. Out of these patients, 61 (0.8%) were treated for restenosis after ICB: 56 patients with completed follow-up could be evaluated. Median age was 65 years, with 80% male patients. 48% of patients had a prior myocardial infarction and 25% had already coronary bypass surgery (CABG). Type B2 lesion was present in 40% and type C lesion in 22.4%. Event rates from SES implantation until 6.6 months follow-up were death 0%, myocardial infarction 3.6%, stroke 2.1%. Target vessel revascularization rate (TVR) was 16.4%, and major adverse cardiovascular or cerebral events (MACCE) or TVR occurred in 17.9% of patients. This TVR rate was higher compared with that of other patients treated with an SES: 8.4% (P = 0.04). During 65 months follow-up MACCE or TVR occurred in 44.6% of patients.

CONCLUSIONS

The treatment of lesions after ICB occurred in 0.8% out of all patients treated with an SES. Clinical event rates during early follow-up were low. However, the TVR rate was 16.4%, which was significantly higher when compared with other SES-treated patients (8.4%, P = 0.04). The treatment of restenosis after ICB with SES seems to be safe and reasonably effective; however, there might be a late catch-up phenomenon.

Capacity Constraints and Cost-Effectiveness: A Discrete Event Simulation for Drug-Eluting Stents

Background. Waiting times for access to care, for example, for diagnostic imaging or surgery, are a highly relevant issue in health care. Waiting or deferred treatment caused by limited resource capacities can affect treatment success, quality of life, and costs. However, when treatment alternatives are compared in economic models, often unrestricted availability of resources is assumed, and dynamic changes in waiting lines remain unconsidered. The objective of this study was to evaluate the impact of potential real-world capacity restrictions and implied waiting lines on cost-effectiveness results and additional model outcomes. Methods. A case study of drug-eluting and bare-metal stent treatment illustrates the effect of hypothetical capacity limitations of daily stenting procedures. Therefore, a decision-analytic model which allows for explicitly defined resource capacities and dynamic waiting lines was built using discrete event simulation. Cost-effectiveness, utilization, waiting time, and budgetary impact of alternative treatment scenarios are analyzed under the assumption of limited and unlimited resource capacities. Results. The compared treatment allocation scenarios in the case study demonstrate that the additional cost for waiting increases the average treatment cost per patient. The different scenarios have different impacts on waiting lines because of the number of repeated interventions. Additionally, this effect leads to changes in cost-effectiveness results for the hypothetical capacity limit. Explicitly modeled capacities allow for further analysis of capacity utilization, waiting lines, and budgetary impact. Conclusion. Our model shows that neglected limited capacities can cause wrong cost-effectiveness results. Therefore, capacities should be explicitly included in decision-analytic models if there is evidence of scarcity.

Prognostic value of the modified American College of Cardiology/American Heart Association lesion morphology classification for clinical outcome after sirolimus-eluting stent placement (results of the prospective multicenter German Cypher Registry)

The modified American College of Cardiology/American Heart Association (ACC/AHA) lesion morphology classification scheme has prognostic impact for early and late outcomes when bare-metal stents are used. Its value after drug-eluting stent placement is unknown. The predictive value of this lesion morphology classification system in patients treated using sirolimus-eluting stents included in the German Cypher Registry was prospectively examined. The study population included 6,755 patients treated for 7,960 lesions using sirolimus-eluting stents. Lesions were classified as type A, B1, B2, or C. Lesion type A or B1 was considered simple (35.1%), and type B2 or C, complex (64.9%). The combined end point of all deaths, myocardial infarction, or target vessel revascularization was seen in 2.6% versus 2.4% in the complex and simple groups, respectively (p = 0.62) at initial hospital discharge, with a trend for higher rates of myocardial infarction in the complex group. At the 6-month clinical follow-up and after adjusting for other independent factors, the composite of cumulative death, myocardial infarction, and target vessel revascularization was nonsignificantly different between groups (11.4% vs 11.2% in the complex and simple groups, respectively; odds ratio 1.08, 95% confidence interval 0.8 to 1.46). This was also true for target vessel revascularization alone (8.3% of the complex group, 9.0% of the simple group; odds ratio 0.87, 95% confidence interval 0.72 to 1.05). In conclusion, the modified ACC/AHA lesion morphology classification system has some value in determining early complications after sirolimus-eluting stent implantation. Clinical follow-up results at 6 months were generally favorable and cannot be adequately differentiated on the basis of this lesion morphology classification scheme.

Long-term follow-up of drug-eluting stents when inserted for on- and off-label indications

This study reports long-term follow-up of the on- and off-label implantation of drug-eluting stents (DESs) in a retrospective study of 1,044 patients. Off-label implantation of DESs was performed for left main coronary artery lesions, bifurcation lesions, bare metal stent restenosis, ostial disease, chronic total occlusions, saphenous vein graft lesions, internal mammary artery graft lesions, left ventricular ejection fraction <30%, and acute myocardial infarction. End points examined were procedural complications, in-hospital myocardial infarction, and acute stent thrombosis; end points examined at follow-up were subacute stent thrombosis, late stent thrombosis, target vessel revascularization, myocardial infarction, death, and major adverse clinical events (MACEs; a composite of death, myocardial infarction, and target vessel revascularization). The study included 364 patients who received a DES on an on-label basis and 680 patients who received a DES on an off-label basis. Patient characteristics were not significantly different between the 2 groups, and there was no difference in procedural complications or acute stent thrombosis (on-label, 0%; off-label, 0.3%; p=0.55). There were no significant differences in subacute stent thrombosis (0% vs 0.6%, p=0.3), late stent thrombosis (1.4% vs 1.2%, p=0.78), death at follow-up (4.9% vs 4.1%, p=0.53), or myocardial infarction (1.9% vs 2.4%, p=0.83). Off-label DES implantation was associated with higher rates of target vessel revascularization (13.2% vs 24.1%, p=0.0001) and MACEs (17.6% vs 28.2%, p=0.0001). Multivariate analysis showed associations between target vessel revascularization and MACEs (respective p values) with bare metal stent restenosis (p=0.001 and p=0.001), diabetes mellitus (p=0.002 and p=0.001), and previous coronary artery bypass grafting (p=0.04 and p=0.01), but not off-label DES implantation (p=1.36 and p=1.16). In conclusion, DES use in the off-label situations studied was safe and was not associated with increased stent thrombosis, myocardial infarction, or death. Multivariate analysis showed that off-label DES implantation was not a risk factor for target vessel revascularization or MACEs.

Sirolimus-eluting stent treatment for unprotected versus protected left main coronary artery disease in widespread clinical routine: 6-month and 3-year clinical follow-up results from the prospective multicentre German Cypher Registry

BACKGROUND

Percutaneous coronary intervention (PCI) of left main coronary artery (LMCA) disease in the bare stent era was limited by high restenosis rates which eventually resulted in sudden death in unprotected cases. Clinical and angiographic restenosis has been substantially reduced by drug-eluting stents, reviving therefore this indication for PCI despite the absence of direct comparative studies with coronary artery bypass graft surgery.

OBJECTIVE

To assess the acute, mid- and long-term outcomes of patients treated with sirolimus-eluting stents for unprotected LMCA stenoses and to compare them with those treated for protected LMCA disease in the same time period from the German Cypher Registry.

SETTING AND PATIENTS

The German Cypher Registry included 6755 patients. Eighty-two patients treated for unprotected LMCA disease were compared with 118 patients treated for protected LMCA stenoses. All patients were treated by sirolimus-eluting stents. The primary end point was death, myocardial infarction (MI) and target vessel revascularisation at 6 months' follow-up. Survival free of MI at the long term was considered as the safety end point.

RESULTS

One-third of the patients in both groups were treated for the distal left main bifurcation. Angiographic success was 98.5% for both groups. The cumulative combined incidence of all-cause death, non-fatal MI and target vessel revascularisation at 6 months was 14.1% in the unprotected LMCA group and 13.1% in the protected group (hazard ratio = 0.81 (95% CI 0.37 to 1.74), p = 0.8). At long-term, death/MI were reported among 20.2% (95% CI 13.5% to 29.6%) of the protected group versus 11.8% (95% CI 6.3% to 21.4%) of the unprotected group (p = 0.2).

CONCLUSION

Sirolimus-eluting stent treatment of unprotected and protected LMCA stenoses is technically feasible in widespread routine clinical use. Acceptable long-term clinical results can be achieved, with no particular safety concerns about treatment of unprotected LMCA disease.

Outcome in the elderly undergoing percutaneous coronary intervention with sirolimus-eluting stents: results from the prospective multicenter German Cypher Stent Registry

BACKGROUND

Patients older than 75 years undergoing percutaneous coronary interventions are at increased risk for major adverse cardiac events strongly influenced by comorbidities. In various randomized trials, sirolimus-eluting stent (SES) implantation has been shown to decrease the incidence of in-stent restenosis and to reduce repeat revascularization regardless of patient age.

METHODS

The present study evaluates the outcome after SES implantation in 954 patients older than 75 years compared with 5801 patients younger than 75 years enrolled in the German Cypher Registry in a routine clinical setting.

RESULTS

The elderly were at higher risk regarding renal failure, diabetes, hypertension, impaired left ventricular function, and 3-vessel disease. The SES implantation resulted in an impressive relief of angina. As expected, in-hospital and 6-month mortality rates were higher in the elderly. However, there was no difference with respect to the rate of major adverse cardiac events (death, myocardial infarction, ischemia-driven target vessel revascularization) at 6-month follow-up.

CONCLUSIONS

Nonfatal complications such as myocardial infarction or repeat target vessel revascularization did not increase with age, even taking patients older than 80 years into account.

Evaluation of hospitals regarding outcomes and baseline risk

Monitoring of hospital performance is increasingly used in the process of improving the quality of health care. Various approaches to quality assessment and publication of the results are discussed. Therefore, a method acceptable for clinicians in the hospitals is urgently needed. As the case mix of the patients differs considerably across hospitals, any assessment based on outcome measures has to be adjusted for the patients' risk profiles. We use a method of calculation and presentation that relates the observed complication rate of one centre to the mean rate that would be expected for similar patients in the other centres. We argue that this procedure might especially meet the demands of clinicians in the centres. Data from 44 hospitals in the German Cypher Stent Registry are used to exemplify the proposed procedure.

RESULTS

A large variation in the cumulative incidence of MACE within 6 months (range 0-12.2%) as well as in the prevalence of selected risk factors was observed across hospitals. Using a logistic prediction model, the differences in risk profiles of the patient populations in the centres resulted in a wide range of expected MACE rates (2.55-5.44%). The outcome of seven centres differed significantly from the expectation.

CONCLUSION

In comparisons of the outcome quality of hospitals, adjustment for the patients' baseline risk by an appropriate method is indispensable.

The Sirolimus-eluting coronary stent in daily routine practice in Germany: trends in indications over the years. Results from the prospective multi-centre German Cypher Stent Registry

BACKGROUND

Drugeluting coronary stents (DES) are increasingly used during percutaneous coronary interventions (PCI). Due to limited budgets in Germany, no special reimbursement has been given for their use and therefore they were mainly used in selected patients.

METHODS

In order to determine the change in indications in patients treated with a Sirolimus-eluting stent (SES) in daily clinical practice between 2002 and 2005, we analysed data from a prospective multi-centre DES registry, the German Cypher Stent Registry.

RESULTS

From April 2002 until September 2005, 11 507 patients at 132 hospitals, who received at least one SES during their PCI, were included. Between 2002 and 2005, the median age of patients increased from 63 years to 66 years (p for trend <0.0001), whereas the prevalence of prior coronary bypass surgery (p<0.0001) and prior PCI (p<0.001) significantly decreased. Initial presentation of patients was stable over time, with a small increase of patients treated for non-ST elevation myocardial infarction (p=0.05). We found a significant increase in the treatment of complex stenoses (p<0.0001) as well as an increase in the proportion of chronic total occlusions (p<0.01). There was a steady increase in the proportion of patients treated for de novo lesions (p<0.0001), which was accompanied by a relative decrease in the proportion of patients treated for in-stent restenosis (p<0.0001). Concerning interventional characteristics a significant increase in the length of SES implanted per lesion, the numbers of SES implanted per lesion as well as an increase of the proportion of patients treated for more than one stenosis during one intervention could be observed (all p<0.0001). There was a significant decrease in the use of glycoprotein II b/IIIa antagonists during the PCI (2002: 26.5 to 14.2% in 2005, p<0.0001). MACE rates until hospital discharge did not change significantly over time.

CONCLUSIONS

Between 2002 and 2005 there were two trends in the use of SES: a) a significant increase in the use of SES for de novo lesions and b) a significant trend to use SES for longer lesions, smaller arteries, more complex lesions and more SES per lesion. In summary these findings indicate that still SES are mainly used in patients with lesions that are at high risk for restenosis.

Incidence and predictors of target vessel revascularization after sirolimus-eluting stent treatment for proximal left anterior descending artery stenoses among 2274 patients fromthe prospectivemulticenter German Cypher Stent Registry

BACKGROUND

Involvement of the proximal LAD is considered an indication for coronary artery bypass graft (CABG) surgery due to the high restenosis rates associated with this location after percutaneous coronary interventions (PCI). This seems to be different, however, when using sirolimus-eluting stents, a finding if proven to be true could have a major impact on clinical decision making regarding the optimal revascularization strategy for these patients.

METHODS

We analyzed 2274 patients treated for proximal LAD stenoses using SES from the German Cypher Stent Registry. The incidence of TVR and other major clinical adverse events were determined and independent predictors of TVR were specified using a multiple logistic regression model.

RESULTS

Event-free survival was achieved in 89.5% of patients. TVR was performed in 179 patients (7.9%) and the combined incidence of all cause death, myocardial infarction and TVR was 10.5% (231 patients). Independent predictors of TVR were multivessel disease (OR 1.74, 95% CI 1.16-2.62, p = 0.008), stent diameter < or = 2.75 mm (OR 1.61, 95% CI 1.10-2.40, p = 0.02) and the administration of GP IIb/ IIIa antagonists (OR 1.60, 95% CI 1.05-2.60, p = 0.03). TVR rate was as high as 11.2% for 2.5 mm SES and as low as 4.0% for 3.5 mm SES (p < 0.001 for trend test).

CONCLUSION

TVR among patients treated with SES for proximal LAD stenoses is low and is related in part to operator dependent factors. Treatment with SES should be considered as an effective treatment for these patients.

Predictors of death or myocardial infarction during follow-up after coronary stenting with the sirolimus-eluting stent. Results from the prospective multicenter German Cypher Stent Registry

BACKGROUND

Drug-eluting coronary stents are the most recent "breakthrough" technology in interventional cardiology. Whereas risk factors influencing restenosis and need for target vessel revascularization are well known, risk factors for dying or developing a myocardial infarction (MI) after drug-eluting coronary stent implantation need to be evaluated yet.

METHODS

We evaluated data from the German Cypher Stent Registry.

RESULTS

From April 2002 to December 2004, 7445 patients at 122 hospitals, who received at least one sirolimus-eluting stent during percutaneous coronary intervention, were included. Complete follow-up at a median of 6.6 months (quartiles 6.1-8.1 months) was available in 6755 patients (91%). Death occurred in 1.8% (120/6755) of patients, nonfatal MI in 2.3% (156/6635), and death or MI in 4.1% (276/6755) of patients. Independent predictors of death or MI were initial presentation with ST-elevation MI or non-ST-elevation MI (OR [odds ratio] 2.21, 95% CI 1.66-2.95, P < .0001), cardiogenic shock (OR 3.05, 95% CI 1.67-5.55, P = .0003), renal insufficiency (OR 1.74, 95% CI 1.24-2.44, P = .0017), reduced left ventricular function (OR 1.74, 95% CI 1.21-2.50, P = .0027), age (per decade) (OR 1.19, 95% CI 1.05-1.36, P = .0058), diabetes mellitus (OR 1.39, 95% CI 1.05-1.84, P = .0183), 3-vessel disease (OR 1.32, 95% CI 0.99-1.77, P = .043), and prior MI (OR 1.35, 95% CI 1.01-1.80, P = .0468), whereas interventional and lesion characteristics showed no significant association.

CONCLUSIONS

These results demonstrate that the most powerful predictors of death or MI after sirolimus-eluting stent implantation during percutaneous coronary intervention are presentation with an acute coronary syndrome, impaired left ventricular ejection fraction, and conventional risk factors for coronary heart disease. Interventional and lesion characteristics do not play a major role.

On- versus off-label use of drug-eluting coronary stents in clinical practice (report from the American College of Cardiology National Cardiovascular Data Registry [NCDR])

Limited data are available on the off-label use of drug-eluting stents (DESs) in clinical practice. We used data from the American College of Cardiology National Cardiovascular Data Registry to describe the rates and outcomes of DES use in 4 common off-label situations: ST-elevation myocardial infarction, in-stent restenosis, coronary artery bypass grafts, and chronic total occlusions. The rates of in-hospital adverse events for each off-label situation were determined and compared with the expected rates calculated from a validated model. From approval of DESs to the end of 2004, a total of 408,033 procedures involved placement of a DES. The use of DESs increased from 19.7% at the start of the study to 78.2% by the end of fourth quarter of 2004. Off-label use of DESs occurred in 24.1% of procedures. The rates of in-hospital adverse events with DES use in ST-elevation myocardial infarction, in-stent restenosis, coronary artery bypass grafting, and chronic total occlusions were lower than expected from the validated model. In conclusion, off-label use of DESs is common and is associated with a low rate of short-term adverse events. Randomized clinical trials are needed to confirm the efficacy of DESs in these clinical and angiographic settings. These data also highlight the importance of multicenter registries in tracking new technologies.

Drug-Eluting Stents and the Future of Coronary Artery Bypass Surgery: Facts and Fiction

The treatment of patients with coronary artery disease continues to evolve. Recent, exciting data on the use of drug-eluting stents in diseased coronary vessels has generated immense enthusiasm within the interventional community leading to claims that "drug-eluting stents will put bypass surgeons out of business." However, despite promising short-term and midterm outcomes of this revolutionary new technology, valid concerns regarding long-term safety and efficacy of drug-eluting stents persist. This review article evaluates current status of drug-eluting stents with special emphasis on real and potential drawbacks of this emerging percutaneous coronary interventional modality and its impact on the practice of coronary artery bypass surgery.

In vivoassessment of coronary artery angioplasty and stent deployment from balloon pressure–volume data

This study assessed the clinical and practical value of angioplasty balloon pressure-volume data, obtained by a computer-controlled balloon inflation device, during standard percutaneous coronary intervention (PCI) procedures. Stent deployment was studied for 57 lesions in 34 patients. Angiographic predilation data were available in 9 patients. Vessel lumen improvement with pre-dilation was determined using the area difference under the pressure-volume curves of two consecutive inflations and compared to the angiographically determined lumen improvement. Stent opening pressure, the inflation volume needed to unfold the stent and the shape of the pressure-volume curve were assessed for differences between stent sizes (diameter, length) and manufacturer types. A Pearson correlation of 0.8 between the pressure-volume area difference and the angiographic lumen improvement was significant (p = 0.01), confirming that pressure-volume curves are useful in assessing lumen improvement after pre-dilation. There was a significant difference in stent opening pressure between stent types but not between different stent sizes (length, diameter). The inflation volume measured during the unfolding process of the stent correlated with the calculated stent lumen when deployed (Pearson correlation: 0.65, p = 0.001). The shape of the pressure-volume curve during stent deployment illustrated differences between different stent sizes (length, diameter) during inflation. Pressure-volume curves obtained from an automatic balloon inflation device have shown their usefulness in providing additional feedback about lumen improvement and the mechanical characteristics and quality of stent deployment.

Sirolimus-eluting stent treatment for isolated proximal left anterior descending artery stenoses. Results from the prospective multi-center German Cypher Registry

BACKGROUND

Stenting of isolated proximal LAD stenoses is still a controversial issue since it is associated with higher target vessel revascularization (TVR) rate than both bypass surgery using the internal mammary artery, and stenting of other coronary artery territories. The sirolimus- eluting stent (SES) has been reported to significantly reduce restenosis rates in de novo coronary lesions. Therefore, we compared patients from the German Cypher Registry treated with SES for isolated proximal LAD lesions with those stented for isolated lesions in the proximal LCX or RCA.

METHODS

A total of 349 patients treated with SES were analyzed. 249 patients were treated for proximal LAD stenosis, and 100 for proximal LCX/RCA stenoses. The combined clinical endpoint was MACCE (death of any cause, non-fatal MI and non-fatal stroke) and TVR at 6 months.

RESULTS

In-hospital events (death, MI and TVR) did not differ significantly between both groups (3.2% for the LAD group vs 2.0% for the LCX/RCA-group, p=0.73). The combined end point of death of any cause, non-fatal MI and non-fatal stroke at six months was 2.6% in the LAD group, and 2.2% in the LCX/RCA group (p=1.0). TVR occurred in 4.8% of the LAD group and in 6.5% of the LCX/RCA group at six months (p=0.58). The percentage of patients free from angina at daily activities was 80.6% in the LAD group, and 77.4% in the LCX/ RCA group (p=0.52).

CONCLUSION

SES once implanted into isolated proximal LAD stenoses appears as effective as reported in other vessel territories. Accordingly, stenting of the proximal LAD using SES might prove a suitable alternative to surgery.

Clinical and angiographic follow-up in patients with Cypher or Taxus stents in populations with high percentage of trial-excluded lesions

BACKGROUND

Drug-eluting stents (DESs) are being used in real life in patients with complex lesions usually excluded from the published trials. It is reasonable to think that the results could be worse, and the performance may be different between DES when these complex lesions are included.

METHODS AND MATERIAL

To investigate this issue, we studied our first 82 patients with DES (54 patients with Cypher (C) and 28 patients with Taxus (T) (129 lesions, with 1.57 lesions per patient). Seventy-one complex lesions were treated with C stent, 41 with T stent, and 17 with no DES. It was a high-risk population, as reflected by 64% unstable angina and 40% diabetes mellitus. Of the 112 DES complex lesions treated, 38% would have been excluded from the Sirius and Taxus IV trials.

RESULTS

The main data on intra-segment angiographic measures showed a late luminal loss lower for the C stent than for the T stent (0.17+/-0.45 and 0.44+/-0.6, P=.02, respectively). The restenosis and target lesion revascularization percentages were also lower for the C stent (8.4% vs. 24.4%, P=.07 and 5.6% vs. 17.1%, P<.05, respectively). In the complex lesions without restenosis, 28% would have been excluded from the trials, while in complex lesions with restenosis, there were 53% (P=.05) (with a homogeneous percentage between the C and T groups). The predictor variables of restenosis in the 112 DES-treated complex lesions were length (P=.03, IC=0.97-1.6) and the pre-reference diameter (P=.06).

CONCLUSIONS

In our experience, the C stent is superior to the T stent when treating populations with a high percentage of complex lesions excluded from the trials.

Angiographic and clinical outcome for the treatment of in-stent restenosis with sirolimus-eluting stent compared to vascular brachytherapy

BACKGROUND

With the use of coronary stents for the treatment of coronary artery disease, in-stent restenosis became a major clinical problem. In this non-randomized study, we examined the use of stent-based delivery of sirolimus (rapamycin) for the treatment of in-stent restenosis in comparison to intracoronary beta-brachytherapy, regarding the clinical effectiveness and the angiographic results for the treatment of in-stent restenosis after 6-9 months.

METHODS AND RESULTS

Between July 2001 and May 2002, 28 patients (65+/-11 years) with instent restenosis were treated with intracoronary brachytherapy. Consecutively, between May 2002 and April 2003, 28 patients (65+/-10 years) with in-stent restenosis were treated with the implantation of a sirolimus-eluting stent (SES). Patients with in-stent restenosis treated by implantation of a SES had significantly lower incidence of in-stent restenosis (1/28 (3.6%) vs 10/28 (36%); p=0.007) and insegment restenosis (4/28 (14%) vs 14/28 (50%); p=0.013) compared to patients treated with brachytherapy. Target lesion and target vessel revascularization rate tended to be lower in the SES group (14 vs 25%) but did not yet reach statistical significance. One patient died in the group treated by implantation of a SES eight months after stenting, one patient suffered from myocardial infarction due to a subtotal in-stent restenosis after brachytherapy. Two patients after brachytherapy underwent surgical revascularization due to recurrent in-stent restenosis similar to the patient with in-stent restenosis after SES implantation.

CONCLUSION

In this study we show the feasibility and safety of the treatment of in-stent restenosis by implantation of sirolimus-eluting stents and demonstrate a lower incidence of recurrent in-stent restenosis as well as lower late luminal loss compared to treatment by intravascular brachytherapy.

Incidence and predictors of target vessel revascularization and clinical event rates of the sirolimus-eluting coronary stent (results from the prospective multicenter German Cypher Stent Registry)

Randomized trials have demonstrated the ability of drug-eluting stents to decrease the risk of restenosis after coronary stent implantation. However, the incidences of major cardiovascular/cerebral adverse events (MACCEs) and target vessel revascularization (TVR) during follow-up in a routine clinical setting remain to be determined. We analyzed data of the multicenter German Cypher Stent Registry. From April 2002 to March 2003, 1,726 patients at 93 hospitals who received >/=1 sirolimus-eluting coronary stent were included. Median follow-up was 6.7 months. During follow-up, death occurred in 1.2% of patients (20 of 1,726), nonfatal myocardial infarction in 2.5% (43 of 1,706), and nonfatal stroke in 0.5% (7 of 1,469). TVR was performed in 8.6% of patients, with percutaneous coronary intervention in 7.3% and coronary artery bypass grafting in 1.5%. The overall rate of MACCEs or TVR was 10.8% (186 of 1,726). Independent predictors of TVR were the target vessel being a bypass graft (odds ratio [OR] 2.43, 95% confidence interval [CI] 1.41 to 4.18, p = 0.001), management of >1 lesion during the same intervention (OR 1.75, 95% CI 1.04 to 2.96, p = 0.035), 2- or 3-vessel disease (OR 1.69, 95% CI 1.05 to 2.72, p = 0.030), and age (per decade; OR 0.82, 95% CI 0.69 to 0.98, p = 0.025). These data confirm the safety and effectiveness of using the sirolimus-eluting stent in daily clinical practice. The management of bypass grafts and multiple lesions in 1 session and the presence of multivessel disease were predictors of MACCEs or TVR.

["Integrated care"--the Essen concept: organizational strategies in the treatment of acute myocardial infarction]

The German "GKV-Modernisierungsgesetz" offers new opportunities for patient care. The concept of "integrated care" provides organizational structures for an standardized treatment of myocardial infarction by bridging the different sectors of the German health care system. Apart from guideline-based therapy, innovative diagnostic (cardiac MRI) and therapeutic (drug-eluting stents) techniques are implemented in the "integrated care" model as well. The "Herzinfarktverbund Essen" is the first national real world experience of the integrated care concept in the treatment of myocardial infarction.

Sirolimus-eluting stents for percutaneous coronary intervention in acute myocardial infarction

BACKGROUND

Given the encouraging results on early restenosis rate with drug-eluting coronary stents, both safety and 6 months outcomes of PCI with sirolimus-eluting stents (SES) in acute myocardial infarction are scarce.

METHODS AND RESULTS

Fifty consecutive patients with acute myocardial infarction were subjected to acute PCI with SES and compared to 50 matched control patients who received a bare metal stent (BMS). All patients were followed over 6 months; in addition repeat angiography was obtained in 88.0% of SES and 92.0% of BMS patients. As a result of matching both groups were similar with regard to demographic, clinical, and infarction characteristics, as well as procedural data and adjunctive medication. SES diameter was 3.0 +/- 0.1 versus 3.3 +/- 0.5 mm with BMS, while the length of stented segment was 24 +/- 11 mm with SES versus 16 +/- 8 mm with BMS (p<0.05). No subacute stent thrombosis occurred in either group. At 6 months, all-cause mortality was 2.0% with SES, and 4.0% with BMS (n. s.); reinfarction rate was 2.0% in both groups, but binary restenosis rate (4.0 versus 18.0%; p<0.05) and target vessel revascularization (TVR) were improved with SES (2.0 versus 16.0%; p<0.05) resulting in lower MACE rate of 6.0 versus 22.0% with BMS (p<0.05).

CONCLUSION

Placement of SES with PCI for myocardial infarction is feasible and as safe as BMS; 6-month outcome is superior with SES due to the lower rate of both angiographic restenosis and TVR.