Meta-analysis of randomized trials of drug-eluting stents versus bare metal stents in patients with diabetes mellitus

Utilization of Non-Drug-Eluting Devices for Inpatient Percutaneous Coronary Intervention in the United States

There is a paucity of data on the contemporary use of non-drug-eluting devices (balloon angioplasty or bare-metal stents) in contemporary percutaneous coronary intervention (PCI) in the United States. We utilized the Nationwide Readmissions Database to identify patients hospitalized to undergo PCI with non-drug-eluting devices from 2016 to 2019. The main outcome of interest was the trends in utilization over the study years. Among 1,870,262 PCI procedures, 127,810 (6.8%) were performed with non-drug-eluting devices; 72% of these were in the setting of acute myocardial infarction (MI). The use of non-drug-eluting devices decreased throughout the study period from 12.9% of all PCI in the first quarter of 2016 to 3.4% in the last quarter of 2019 (p <0.001). Factors associated with their use included advanced age and high bleeding risk. Only a small percentage were used as a bridge to coronary artery bypass graft surgery (2%) and for treatment of in-stent restenosis (3%). The in-hospital mortality was 5.8% for the entire cohort and 6.6% when the indication for use was an acute MI. In patients presenting with an acute MI, reinfarction within 30 days was common and occurred in 18% of the patients. In conclusion, the use of non-drug-eluting devices in PCI in the United States decreased from 2016 to 2019. Factors associated with their use included old age and high bleeding risk. Due to suboptimal outcomes in patients currently being treated with non-drug-eluting devices, there remains an unmet clinical need for alternative treatment options.

Percutaneous coronary intervention in diabetic versus non-diabetic patients with prior coronary artery bypass grafting: a propensity score matching study

BACKGROUND

The target of this study was to explore the outcomes of percutaneous coronary intervention (PCI) in diabetic versus non-diabetic patients with prior coronary artery bypass grafting (CABG) surgery.

METHODS

Seven hundred and twenty four patients who had previously received CABG and had been treated using PCI combined with drug-eluting stents (DES) between 2009 and 2017 were selected for a retrospective study and allocated into either a diabetes mellitus (DM) or non-diabetes mellitus (No DM) group. A 1:1 propensity score-matched evaluation was conducted and risk adjusted for analysis. The primary outcomes were cardiac death, myocardial infarction, heart failure and revascularization, with a median follow-up duration of 5.13 years.

RESULTS

After matching, two-, 5- and 8-year event rate of overall major adverse cardiac events (MACEs) were found to be higher in the DM group (No DM vs DM:15.3, 30.9, 38.5% vs 19.8, 37.8, 52.2%, respectively), although no significant difference was found in the event rate of overall MACEs (hazard ratio [HR]: 1.35; 95% confidence interval [CI]: 1.00 to 1.83 for DM vs No DM; P = 0.052), cardiac death (HR: 0.94; 95% CI: 0.45 to 1.95; P = 0.871), MI (HR: 1.49; 95% CI: 0.95 to 2.32; P = 0.080), HF (HR: 1.54; 95% CI: 0.90 to 2.63 for; P = 0.120) or revascularization (HR: 1.07; 95% CI: 0.72 to 1.59; P = 0.747). Subgroup analysis of PCI in only the NCA showed MACEs (adjusted HR: 1.13; 95% CI: 0.85 to 1.49 for DM vs No DM; P = 0.325), cardiac death (adjusted HR: 0.85; 95% CI: 0.41 to 1.78 for DM vs No DM; P = 0.781), MI (adjusted HR: 1.32; 95% CI: 0.84 to 2.01 for DM vs No DM; P = 0.069), HF (adjusted HR: 1.41; 95% CI: 0.87 to 2.27 for DM vs No DM; P = 0.211) or repeated revascularization (adjusted HR: 0.93; 95% CI: 0.64 to 1.37 for DM vs No DM; P = 0.836).

CONCLUSIONS

Compared with non-diabetic patients with prior CABG, subsequent implantation of DES in the native coronary artery of diabetic patients resulted in apparently similar outcomes.

TRIAL REGISTRATION

This study was not registered in an open access database.

ANMCO/GICR-IACPR/SICI-GISE Consensus Document: the clinical management of chronic ischaemic cardiomyopathy

Stable coronary artery disease (CAD) is a clinical entity of great epidemiological importance. It is becoming increasingly common due to the longer life expectancy, being strictly related to age and to advances in diagnostic techniques and pharmacological and non-pharmacological interventions. Stable CAD encompasses a variety of clinical and anatomic presentations, making the identification of its clinical and anatomical features challenging. Therapeutic interventions should be defined on an individual basis according to the patient's risk profile. To this aim, management flow charts have been reviewed based on sustainability and appropriateness derived from recent evidence. Special emphasis has been placed on non-pharmacological interventions, stressing the importance of lifestyle changes, including smoking cessation, regular physical activity, and diet. Adherence to therapy as an emerging risk factor is also discussed.

Choosing the right coronary stent in the modern era

Research and development in the field of coronary stent design is a fast-evolving and fascinating journey. A device that was once introduced to salvage acute closure associated with balloon angioplasty is now the standard of care for many patients with coronary artery disease. Newer generation stents are the product of remarkable progress in technology and innovation, driven by the need to make the stents easier to deliver and to improve their safety and efficacy. As such, the design of these stents has become quite sophisticated and complex. The number of available stents has increased giving patients and physicians more choices on one hand, but also created confusion in selecting the optimal stent for a given patient. Although a 'one size fits all' approach may not be reasonable, several randomized trials have attested to the efficacy and safety of newer generation durable polymer drug eluting stents. This article discusses the evidence base to support various stent choices in contemporary practice.

Comparison of dual versus triple antiplatelet therapy after drug-eluting stent according to stent length (from the pooled analysis of DECLARE trials)

There are no practical criteria for the use of triple antiplatelet therapy after drug-eluting stent (DES) implantation. In our present report, pooled analysis of 3 randomized studies in patients with diabetes mellitus (Drug-Eluting Stenting Followed by Cilostazol treatment reduces LAte Restenosis in patients with diabetes mellitus trial) and long coronary narrowings (Drug-Eluting Stenting Followed by Cilostazol Treatment Reduces Late Restenosis in Patients with Long Coronary Lesions trials I and II) compared triple (aspirin, clopidogrel, and cilostazol; triple group, n = 700) and dual antiplatelet therapies (aspirin and clopidogrel; dual group, n = 699) after DES implantation. Among pooled population (n = 1,399 patients), 1,173 patients with follow-up angiography were divided into 3 stent length categories (≤20, 20 to 40, and >40 mm). There was no statistical significance of in-stent restenosis (ISR) in ≤20- and 20- to 40-mm categories between 2 groups. However, ISR rate was significantly reduced in triple versus dual group in >40-mm stent length category (12.4% vs 22.1%, p = 0.008). In diabetic patients, triple group also showed significant reduction in the ISR rate in >40-mm stent length category (15.4% vs 32.3%, p = 0.003). According to postprocedural minimal lumen diameter, triple group showed a trend toward a lower ISR than that of the dual group in all categories (p = 0.033 for ≤2.5 mm, p = 0.087 for 2.5 to 3.0 mm, and p = 0.119 for >3.0 mm). In conclusion, the triple group had a significantly reduced ISR in patients with >40-mm stent length after DES implantation compared with the dual group. Therefore, this suggestion for use of triple antiplatelet therapy could be easily applied after DES implantation in routine clinical practice.

Comparison of drug-eluting and bare-metal stents in patients with diabetes undergoing primary percutaneous coronary intervention: what is the evidence?

A best evidence topic was written according to a structured protocol. The question addressed was, should the practising interventional cardiologist use drug-eluting stents (DESs) or bare-metal stents (BMSs) when undertaking primary percutaneous coronary intervention (PCI) in diabetic patients. The relevant outcomes that were used to determine the answer to this question included: in-stent restenosis, target vessel revascularization (TVR), mortality, myocardial infarction and in-stent thrombosis. The OVID Medline database was used to carry out the reported search for abstracts of relevant journal articles. Altogether 102 papers were found, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. From the evidence available, we conclude that in-stent restenosis is less likely to occur over a follow-up of at least 6 months if a DES is used instead of a BMS. Furthermore, TVR is less likely to be required in diabetic patients who receive a DES in comparison with a BMS. Nevertheless, no significant difference in mortality between stents was detected by the studies reviewed. This included no difference in the incidence of cardiac and non-cardiac causes of death. There was evidence showing that DESs are associated with a decrease in the risk of myocardial infarction and, in particular, a decrease in non-Q-wave myocardial infarction. However, there was also conflicting evidence demonstrating no significant difference in the incidence of myocardial infarction between diabetic patients who had received a BMS or a DES. Moreover, the available evidence showed no significant difference in the risk of in-stent thrombosis for all DESs with the exception of Sirolimus eluting stents in which the evidence was not consistent. In summary, the available evidence supports the use of DESs over BMSs in diabetic patients undergoing primary PCI.

Percutaneous versus surgical interventions for coronary artery disease in those with diabetes mellitus

Diabetes mellitus (DM) is a metabolic disorder of multiple etiologies that causes long-term damage of various organs including the cardiovascular system. A consistent observation shows that DM amplifies the risk of cardiovascular events by 4- to 6-fold. Since coronary artery disease (CAD) in diabetic patients exhibits diffuse and accelerated lesions, invasive revascularization continues to be a challenge and has worse outcomes than patients without DM. Owing to the pathogenesis of DM and the presence of severe endothelial dysfunction, investigators have been trying to find new treatment modalities that could target the treatment of the disease rather than the treatment of the lesion. Until new treatment modalities are proven and gain acceptance, invasive revascularization remains to be the choice of treatment in such patients. The focus of this review is to compare the results of percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for the treatment of stable CAD in patients with DM.

Meta-analysis comparing efficacy and safety of first generation drug-eluting stents to bare-metal stents in patients with diabetes mellitus undergoing primary percutaneous coronary intervention

Several concerns have emerged regarding the higher risk for stent thrombosis (ST) after drug-eluting stent (DES) implantation, especially in the setting of ST-segment elevation myocardial infarction (STEMI). Few data have been reported so far in patients with diabetes mellitus, which is associated with high rates of target vessel revascularization after bare-metal stent (BMS) implantation but also higher rates of ST after DES implantation. Therefore, the aim of this study was to perform a meta-analysis of individual patients' data to evaluate the long-term safety and effectiveness of DES compared with BMS in patients with diabetes who undergo primary percutaneous coronary intervention for STEMI. Published reports were scanned by formal searches of electronic databases (MEDLINE and CENTRAL). All completed randomized trials of DES for STEMI were examined. No language restrictions were enforced. Individual patients' data were obtained from 11 of 13 trials, including a total of 972 patients with diabetes (616 [63.4%] randomized to DES and 356 [36.6%] to BMS). At long-term follow-up (median 1,095 days, interquartile range 1,087 to 1,460), DES significantly reduced the occurrence of target vessel revascularization (hazard ratio 0.42, 95% confidence interval 0.29 to 0.59, p <0.0001), without any significant difference in terms of mortality, late reinfarction, and ST (>1 year) with DES. In conclusion, this meta-analysis, based on individual patients' data from 11 randomized trials, showed that among patients with diabetes with STEMIs who undergo primary percutaneous coronary intervention, sirolimus-eluting stents and paclitaxel-eluting stents, compared with BMS, are associated with a significant reduction in target vessel revascularization at long-term follow-up, without any apparent concern in terms of mortality, despite the trend toward higher rates of reinfarction and ST.

Serial greyscale and radiofrequency intravascular ultrasound assessment of plaque modification and vessel geometry at proximal and distal edges of bare metal and first-generation drug-eluting stents

BACKGROUND

Little is known about the correlation between modifications in plaque composition at stent edges and the changes in vessel geometry. This study sought to evaluate, by serial greyscale intravascular ultrasound (IVUS) and Virtual Histology intravascular ultrasound (VH-IVUS), the modifications in plaque composition at the edges of drug-eluting and bare metal stents and the correlation of these findings with changes in the measurements of vessel, lumen and plaque area at those segments.

METHODS AND RESULTS

Single-centre, prospective and randomised (1:1) evaluation of 40 patients with acute coronary syndrome treated with bare metal (Driver; Medtronic, Santa Clara, CA, USA; n=20 patients) or drug-eluting stents (Cypher; Cordis, Miami Lakes, FL, USA; n=20 patients). IVUS and VH-IVUS assessments were done post-procedure and at nine months. Primary endpoint included the modification in vessel, lumen and plaque area and in the composition of the plaque in the mean time between the baseline and follow-up procedure. At the proximal edge of the vessel treated with the Cypher stent, a trend toward positive vessel remodelling (D=+0.6 mm², p=0.06) was observed while at the distal edge, less plaque growth (D=+0.2 mm² vs. D=+1.1 mm², p<0.001), resulted in a larger lumen area at follow-up. By VH, there was a marked reduction in the percentage of fibrotic tissue and necrotic core at the edges of both stents and a positive correlation was seen between increase in percentage of fibro-fatty component and increase in plaque area (r=0.78, p=0.01).

CONCLUSION

Patients treated with drug-eluting stents (DES) experienced less plaque growth, especially at the distal edge of the stents. Modifications in plaque composition, with increase in fibrofatty tissue component, may partially explain these findings.

The sirolimus-eluting Cypher Select coronary stent for the treatment of bare-metal and drug-eluting stent restenosis: insights from the e-SELECT (Multicenter Post-Market Surveillance) registry

OBJECTIVES

This study sought to compare the 1-year safety and efficacy of Cypher Select or Cypher Select Plus (Cordis Corporation, Bridgewater, New Jersey) sirolimus-eluting stents (SES) with the treatment of bare-metal stents (BMS) and drug-eluting stent (DES) in-stent restenosis (ISR) in nonselected, real-world patients.

BACKGROUND

There is paucity of consistent data on DES for the treatment of ISR, especially, DES ISR.

METHODS

The e-SELECT (Multicenter Post-Market Surveillance) registry is a Web-based, multicenter and international registry encompassing virtually all subsets of patients and lesions treated with at least 1 SES during the period from 2006 to 2008. We enrolled in this pre-specified subanalysis all patients with at least 1 clinically relevant BMS or DES ISR treated with SES. Primary endpoint was major adverse cardiac events and stent thrombosis rate at 1 year.

RESULTS

Of 15,147 patients enrolled, 1,590 (10.5%) presented at least 1 ISR (BMS group, n = 1,235, DES group, n = 355). Patients with DES ISR had higher incidence of diabetes (39.4% vs. 26.9%, p < 0.001), renal insufficiency (5.8% vs. 2.3%, p = 0.003), and prior coronary artery bypass graft (20.5% vs. 11.8%, p < 0.001). At 1 year, death (1.4% for BMS vs. 2.1% for DES, p = 0.3) and myocardial infarction (2.4% for BMS and 3.3% for DES, p = 0.3) rates were similar, whereas ischemia-driven target lesion revascularization and definite/probable late stent thrombosis were higher in patients with DES ISR (6.9% vs. 3.1%, p = 0.003, and 1.8% vs. 0.5%, p = 0.04, respectively).

CONCLUSIONS

Use of SES for either BMS or DES ISR treatment is safe and associated with low target lesion revascularization recurrence and no apparent safety concern.

Three-year clinical outcome in type 2 diabetic patients with drug-eluting stents versus bare-metal stents with pioglitazone

AIMS

The aim of this study was to examine outcome subsequent to implantation of bare-metal stents (BMS) with pioglitazone, which are novel insulin-sensitizing agents, and drug-eluting stents (DES) in patients with diabetes.

METHODS AND RESULTS

A total of 139 consecutive Type 2 diabetic patients treated with stent were followed up for 3 years. Data on death, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis were ascertained from January 2003 to January 2006. Eighty-nine patients were treated with a BMS with pioglitazone, and 50 patients were treated with a DES. The incidence of MI was 1.1% in the BMS with pioglitazone group, 4.0% in the DES group [relative risk RR):0.52; 95% CI: 0.10-2.56]. The incidence of TLR was 22.5% in the BMS with pioglitazone group, 28.0% in the DES group (RR 0.89; 95% CI: 0.65-1.22). The incidence of stent thrombosis was 1.0% in the BMS with pioglitazone group, 4.0% in the DES group (RR 0.52; 95% CI: 0.10-2.56). Overall 3-year mortality was similar in the two groups (RR 0.77; 95% CI: 0.34-1.74).

CONCLUSIONS

During 3 years of follow-up, patients treated with BMS with pioglitazone had similar risks of death, TLR, MI, and stent thrombosis compared with patients treated with DES.

Temporal trends in the use of drug-eluting stents for approved and off-label indications: a longitudinal analysis of a large multicenter percutaneous coronary intervention registry

BACKGROUND

We sought to examine the temporal variations in the rate of both bare-metal stent (BMS) and drug-eluting stent (DES) use for off-label indications after the reports of an increased risk of very late stent thrombosis in patients with DES at the 2006 meeting of the European Society of Cardiology (ESC).

HYPOTHESIS

To determine whether the decrease in use of DES has affected both on and off-label indications.

METHODS

The study cohort included patients undergoing coronary intervention in a large regional registry, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). Patient demographic and clinical characteristics for patients with DES in the third quarter of 2006 (pre-ESC) were compared to those from the fourth quarter of 2008 (post-guideline changes). Use of DES for off-label indications, such as ST-segment elevation myocardial infarction (STEMI), in-stent restenosis (ISR), and saphenous vein graft (SVG) interventions, were evaluated.

RESULTS

The overall deployment of DES fell sharply from 83% pre-ESC to a plateau of 58% in the first quarter of 2008. This corresponded to a rise in BMS use, while angioplasty procedures stayed the same. The STEMI subgroup showed the most dramatic change, from 78% to only 36%. Off-label use in SVGs showed a similar trend, from 74% to 43%. Drug-eluting stent deployment for ISR was less affected, though it also fell 25% (from 79%-56%).

CONCLUSIONS

The use of DES has fallen dramatically from June 2006 to December 2008, particularly for nonapproved indications. Our study provides a real-world assessment of contemporary change in DES use in response to the presentation of negative observational studies.

Comparison of 2-year clinical outcomes with sirolimus and paclitaxel-eluting stents for patients with diabetes: results of the Registro Regionale AngiopLastiche Emilia-Romagna Registry

BACKGROUND

Long-term outcomes of percutaneous coronary interventions (PCI) with sirolimus-eluting stents (SES) compared to paclitaxel-eluting-stents (PES) in unselected diabetics in routine practice is still debated.

OBJECTIVE

This study compared the 2-year incidence of MACE (all-cause mortality, nonfatal myocardial infarction and target vessel revascularization) of SES and PES in a real-world setting of patients with diabetes.

DESIGN

Observational, multicenter, nonrandomized study.

SETTING

Prospective web-based registry (REAL Registry; study period, 2002-2005) comprising all 13 hospitals performing PCI.

PATIENTS

Among the 945 eligible patients treated with either SES alone (n = 606) or PES alone (n = 339), 29% were insulin-requiring, 72% had multivessel coronary disease, 26% had prior myocardial infarction and 10% had poor left ventricular function.

MEASUREMENTS

Unadjusted and propensity score-adjusted 2-year clinical outcome.

RESULTS

After propensity score adjustment, 2-year MACE incidence in the SES and PES groups was equivalent (23.3% vs. 23.7%, HR 1.01, 95%CI 0.72-1.42, P = 0.96). Adjusted 2-year angiographic stent thrombosis occurred in 1.1% of the SES patients versus 2.6% of the PES patients (P = 0.15). In this large, real-world, diabetic population treated with DES, there was no difference in outcome between SES and PES. Further studies are needed to demonstrate the long-term safety of different types of DES in patients with diabetes.

Paclitaxel-eluting versus sirolimus-eluting stents in diabetes mellitus: a report from the National Heart, Lung, and Blood Institute Dynamic Registry

BACKGROUND

Diabetes is a powerful predictor of adverse events in patients undergoing percutaneous coronary intervention. Drug-eluting stents reduce restenosis rates compared with bare metal stents; however, controversy remains regarding which drug-eluting stents provides greater benefit in patients with diabetes. Accordingly, we compared the safety and efficacy of sirolimus-eluting stents (SES) with paclitaxel-eluting stents (PES) among diabetic patients in a contemporary registry.

METHODS AND RESULTS

Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated 2-year outcomes of diabetic patients undergoing percutaneous coronary interventions with SES (n=677) and PES (n=328). Clinical and demographic characteristics, including age, body mass index, insulin use, left ventricular function, and aspirin/clopidogrel use postprocedure, did not differ significantly between the groups except that PES-treated patients had a greater frequency of hypertension and hyperlipidemia. At the 2-year follow-up, no significant differences were observed between PES and SES with regard to safety or efficacy end points. PES- and SES-treated patients had similar rates of death (10.7% versus 8.2%, P=0.20), death and myocardial infarction (14.9% versus 13.6%, P=0.55), repeat revascularization (14.8% versus 17.8%, P=0.36), and stent thrombosis (1.3% versus 1.3%, P=0.95). After adjustment, no significant differences between the 2 stent types in any outcome were observed.

CONCLUSIONS

PES and SES are equally efficacious and have similar safety profiles in diabetic patients undergoing percutaneous coronary interventions in clinical practice.

Comparative healing response after sirolimus- and paclitaxel-eluting stent implantation in a pig model of restenosis

OBJECTIVE

We compared local vessel healing and inflammatory responses associated with nonoverlapping sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES).

BACKGROUND

Sirolimus and paclitaxel may have different effects on vascular healing. In the present study, we analyzed the local histologic effects of drug-eluting stents (DES).

METHODS

We placed 43 stents (22 PES and 21 SES) in 16 Yucatan minipigs. Stents were randomly assigned and placed in the left anterior descending, circumflex, or right coronary arteries (one stent per artery), covering a region previously injured by balloon angioplasty.

RESULTS

Histopathologic analysis showed that the distribution of injury scores was similar between the two stent groups, reflecting the homogeneity of coronary injury secondary to balloon overstretch. Electron microscopy showed complete endothelialization in most cases. Incomplete endothelialization was present in 12.5% of PES and almost 20% of SES at 30 days. In the PES group, moderate to severe inflammation was found in eight arteries, whereas only one vessel had moderate inflammation in the SES group. Severe inflammation was observed significantly more often in the PES than in the sirolimus group (P = 0.006). With the PES group, stent struts overlying side branches had a significantly higher frequency of poor endothelialization scores than did stent struts that did not overlay side branches (P = 0.006).

CONCLUSIONS

In this preclinical study in a pig model of in-stent restenosis, implantation of nonoverlapping DES was associated with local inflammatory reactions and decreased endothelial repair. Impaired endothelialization was visualized in the struts overlying side branches.

Drug-Eluting or Bare-Metal Stenting in Patients With Diabetes Mellitus

Background— Patients with diabetes mellitus (DM) are at high risk for restenosis, myocardial infarction, and cardiac mortality after coronary stenting, and the long-term safety of drug-eluting stents (DES) relative to bare-metal stents (BMS) in DM is uncertain. We report on a large consecutive series of patients with DM followed up for 3 years after DES and BMS from a regional contemporary US practice with mandatory reporting.

Methods and Results— All adults with DM undergoing percutaneous coronary intervention with stenting between April 1, 2003, and September 30, 2004, at all acute care nonfederal hospitals in Massachusetts were identified from a mandatory state database. According to index admission stent type, patients were classified as DES treated if all stents were drug eluting and as BMS treated if all stents were bare metal; patients treated with both types of stents were excluded from the primary analysis. Mortality rates were obtained from vital statistics records, and myocardial infarction and revascularization rates were obtained from the state database with complete 3 years of follow-up on the entire cohort. Risk-adjusted mortality, myocardial infarction, and revascularization differences (DES−BMS) were estimated with propensity-score matching based on clinical, procedural, hospital, and insurance information collected at the index admission. DM was present in 5051 patients (29% of the population) treated with DES or BMS during the study. Patients with DM were more likely to receive DES than BMS (66.1% versus 33.9%; P <0.001). The unadjusted cumulative incidence of mortality at 3 years was 14.4% in DES versus 22.2% in BMS ( P <0.001). Based on propensity-score analysis of 1:1 matched DES versus BMS patients (1476 DES:1476 BMS), the risk-adjusted mortality, MI, and target vessel revascularization rates at 3 years were 17.5% versus 20.7% (risk difference, −3.2%; 95% confidence interval, −6.0 to −0.4; P =0.02), 13.8% versus 16.9% (−3.0%; 95% confidence interval, −5.6 to 0.5; P =0.02), and 18.4% versus 23.7% (−5.4%; confidence interval, −8.3 to −2.4; P <0.001), respectively.

Conclusions— In a real-world diabetic patient population with mandatory reporting and follow-up, DES were associated with reduced mortality, myocardial infarction, and revascularization rates at long-term follow-up compared with BMS.

Meta-analysis comparison (nine trials) of outcomes with drug-eluting stents versus bare metal stents in patients with diabetes mellitus

In patients with diabetes mellitus, outcome after drug-eluting stent (DES) versus bare metal stent (BMS) implantation remains under investigation; although lower reintervention rates were reported, incidence of death and myocardial infarction (MI) during follow-up is not completely characterized. Thus, we performed a meta-analysis of available randomized studies evaluating follow-up events of DESs versus BMSs in patients with diabetes mellitus. Randomized trials reporting outcome of DES versus BMS in diabetic patients with a follow-up > or =6 months were included. Outcomes analyzed were (1) death, (2) MI, (3) in-stent restenosis (ISR) and target lesion revascularization (TLR), and (4) stent thrombosis. Data were extracted by 2 independent reviewers. A total of 9 trials, including 1,141 patients, were found. ISR occurred in 8% of patients with DESs versus 41% of those with BMSs (odds ratio [OR] 0.13, 95 confidence interval [CI] 0.09 to 0.20, p <0.00001) and TLR in 8% versus 27% (OR 0.23, 95% CI 0.16 to 0.33, p <0.00001). There was no difference in the incidence of stent thrombosis (1.1% vs 1.2%, p = 0.98) or death (2.4% vs 2.3%, p = 0.91). MI occurred in 3.5% of patients with DESs versus 7.2% of those with BMSs (52% risk decrease, p = 0.02). Decrease of ISR with DESs was observed in noninsulin-treated (OR 0.17, 95% CI 0.11 to 0.26, p <0.00001) and insulin-treated (OR 0.22, 95% CI 0.13 to 0.37, p <0.00001) patients. In conclusion, diabetic patients receiving DESs have lower risk of ISR and TLR versus those treated with BMSs; use of DESs in patients with diabetes mellitus significantly decreases the incidence of MI during follow-up, without affecting mortality or stent thrombosis.

Effect of thiazolidinediones on in-stent restenosis in patients after coronary stenting: a meta-analysis of randomized controlled trials

BACKGROUND

Recent experimental studies have demonstrated that thiazolidinediones (TZDs) therapy inhibits proliferation and migration of vascular smooth muscle cells, accelerates endothelium reparation and attenuates neointimal hyperplasia. It implies that TZDs therapy may have beneficial effects on in-stent restenosis (ISR). Several small-sample clinical trials have evaluated the effect of TZDs therapy on ISR, however, the results were inconsistent across trials.

METHODS AND RESULTS

We performed a meta-analysis of all relevant randomized controlled trials to evaluate the effect of TZDs therapy on in-stent restenosis in patients undergoing coronary stenting. Eight trials involving 366 patients were included in this study. TZDs therapy was associated with a significant reduction in the risk of ISR in both diabetic (RR 0.37, 95% CI 0.23-0.59; P<0.0001) and non-diabetic patients (RR 0.16, 95% CI 0.05-0.45; P=0.0006). TZDs therapy was associated with a significant reduction in late lumen loss (WMD -0.54 mm, 95% CI -0.87 mm, -0.22 mm; P=0.001), percent diameter stenosis (WMD -15.7%, 95% CI -19.4%, -12.0%; P<0.00001), neointimal area/volume (SMD -0.76, 95% CI -1.13, -0.39; P<0.0001) and target lesion revascularization (RR 0.32, 95% CI 0.18-0.57; P=0.0001).

CONCLUSIONS

Our study suggests that TZDs therapy is an effective strategy in preventing ISR in both diabetic and non-diabetic patients undergoing coronary stenting. More studies, especially large multi-centre RCTs, are still warranted to further clarify the anti-restenotic effect of TZDs therapy.