Efficacy and safety of drug-eluting stents in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) update 2022

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Interventional and Therapeutics (CVIT) society proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018. Updated guidelines for the management of AMI were published by the European Society of Cardiology (ESC) in 2017 and 2020. Major changes in the guidelines for STEMI patients included: (1) radial access and drug-eluting stents (DES) over bare-metal stents (BMS) were recommended as a Class I indication, (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. In 2020, updated guidelines for Non-ST-Elevation Myocardial Infarction (NSTEMI) patients, the followings were changed: (1) an early invasive strategy within 24 h is recommended in patients with NSTEMI as a Class I indication, (2) complete revascularization in NSTEMI patients without cardiogenic shock is considered as Class IIa recommendation, and (3) in patients with atrial fibrillation following a short period of triple antithrombotic therapy, dual antithrombotic therapy (e.g., DOAC and single oral antiplatelet agent preferably clopidogrel) is recommended, with discontinuation of the antiplatelet agent after 6 to 12 months. Furthermore, an aspirin-free strategy after PCI has been investigated in several trials those have started to show the safety and efficacy. The Task Force on Primary PCI of the CVIT group has now proposed the updated expert consensus document for the management of AMI focusing on procedural aspects of primary PCI in 2022 version.

Drug-coated balloon treatment in coronary artery disease: Recommendations from an Asia-Pacific Consensus Group

Coronary artery disease (CAD) is currently the leading cause of death globally, and the prevalence of this disease is growing more rapidly in the Asia-Pacific region than in Western countries. Although the use of metal coronary stents has rapidly increased thanks to the advancement of safety and efficacy of newer generation drug eluting stent (DES), patients are still negatively affected by some the inherent limitations of this type of treatment, such as stent thrombosis or restenosis, including neoatherosclerosis, and the obligatory use of dual antiplatelet therapy (DAPT) with unknown optimal duration. Drug-coated balloon (DCB) treatment is based on a leave-nothing-behind concept and therefore it is not limited by stent thrombosis and long-term DAPT; it directly delivers an anti-proliferative drug which is coated on a balloon after improving coronary blood flow. At present, DCB treatment is recommended as the first-line treatment option in metal stent-related restenosis linked to DES and bare metal stent. For de novo coronary lesions, the application of DCB treatment is extended further, for conditions such as small vessel disease, bifurcation lesions, and chronic total occlusion lesions, and others. Recently, several reports have suggested that fractional flow reserve guided DCB application was safe for larger coronary artery lesions and showed good long-term outcomes. Therefore, the aim of these recommendations of the consensus group was to provide adequate guidelines for patients with CAD based on objective evidence, and to extend the application of DCB to a wider variety of coronary diseases and guide their most effective and correct use in actual clinical practice.

Impact of stent generation on 2-year clinical outcomes in ST-segment elevation myocardial infarction patients with multivessel disease who underwent culprit-only or multivessel percutaneous coronary intervention

BACKGROUND

Data concerning the impact of stent generation on long-term outcomes in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) who underwent primary percutaneous coronary intervention (PCI) with culprit-only PCI (C-PCI) or multivessel PCI (M-PCI) are limited.

METHODS

A total of 7,266 patients were separated into the two groups, a C-PCI (n = 4,901) or M-PCI group (n = 2,365). The primary endpoint was the occurrence of major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction, and any repeat revascularization. The secondary endpoint was the cumulative incidence of stent thrombosis (ST) at 2 years.

RESULTS

The cumulative incidence of MACE was significantly higher in the bare-metal stents (BMS) group than the first-generation (1G)-drug-eluting stents (DES) (C-PCI: adjusted hazard ratio [aHR], 1.940; 95% confidence interval [CI], 1.389-2.709; p < .001; M-PCI: aHR, 1.544; 95% CI, 1.099-2.074; p = .038), and the second-generation (2G)-DES group (C-PCI: aHR, 2.271; 95% CI, 1.657-3.114; p < .001; M-PCI: aHR, 2.999; 95% CI, 1.899-4.704; p < .001). In the M-PCI group, 1G-DES showed a higher incidence of MACE compared with 2G-DES (aHR, 1.639; 95% CI, 1.028-2.614; p = .004). The cumulative incidences of ST in the both groups were similar.

CONCLUSION

The cumulative incidence of MACE was the lowest for 2G-DES, the highest for BMS, and intermediate for 1G-DES in the STEMI patients with MVD after C-PCI or M-PCI. However, cumulative incidence of ST in the two different reperfusion strategy groups was similar regardless of stent generation.

HIV status and type of coronary stent placed in patients presenting with ST-elevation myocardial infarction

BACKGROUND

Drug-eluting stents (DES) outperform bare-metal stents (BMS) in reducing target vessel revascularization following a percutaneous coronary intervention (PCI). Little is known about the types of stents placed in HIV-positive patients presenting with ST-segment elevation myocardial infarctions (STEMIs).

METHODS

We used the 2003-2013 National Inpatient Sample to identify adults of 18 years or older presenting with STEMI. We evaluated differences in stent type placed following STEMIs on the basis of HIV status. Temporal trends in the use of PCI, DES, and BMS were studied on the basis of HIV status.

RESULTS

Of 1 695 947 patients with STEMI, 5887 (0.3%) were HIV-positive patients. Following STEMIs, HIV-positive patients were equally likely to have PCI compared with HIV-negative patients [adjusted odds ratio (AOR): 1.04, 95% confidence interval (CI): 0.89-1.21, P=0.63]. However, HIV-positive patients were less likely to have DES (AOR: 0.83, 95% CI: 0.73-0.94, P=0.003) and more likely to have BMS (AOR: 1.26, 95% CI: 1.11-1.45, P=0.001). Over the 11-year period observed, there were increases in PCI following STEMIs in both HIV-positive and HIV-negative patients (all Ptrend<0.001). There were significant increases in the use of DES in HIV-negative patients [adjusted odds ratio (AOR) per year: 1.07, 95% CI: 1.06-1.09, Ptrend<0.001] and significant decreases in the use of BMS (AOR per year: 0.93, 95% CI: 0.92-0.94, Ptrend<0.001). Significant trends showing changed practice patterns in the use of DES and BMS among HIV-positive patients were not observed.

CONCLUSION

Over a decade, there were significant increases in the use of PCI following STEMIs in both HIV-negative and HIV-positive patients. Although HIV-positive patients presenting with STEMIs were as likely as HIV-negative patients to undergo PCI, they were less likely to be treated with DES and more likely to receive BMS. Highlighting these observations will hopefully bring renewed attention to best practices for all STEMI patients.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

Routine Angiographic Follow-Up versus Clinical Follow-Up after Percutaneous Coronary Intervention in Acute Myocardial Infarction

PURPOSE

Differences in the utility of routine angiographic follow-up (RAF) and clinical follow-up (CF) after percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) are not well understood. The present study aimed to compare the 3-year clinical outcomes of RAF and CF in AMI patients who underwent PCI with drug-eluting stents (DES).

MATERIALS AND METHODS

A total of 774 consecutive AMI patients who underwent PCI with DES were enrolled. RAF was performed at 6 to 9 months after index PCI (n=425). The remaining patients were medically managed and clinically followed (n=349); symptom-driven events were captured. To adjust for any potential confounders, a propensity score matched analysis was performed using a logistic regression model, and two propensity-matched groups (248 pairs, n=496, C-statistic=0.739) were generated. Cumulative clinical outcomes up to 3 years were compared between RAF and CF groups.

RESULTS

During the 3-year follow-up period, the cumulative incidences of revascularization [target lesion revascularization: hazard ratio (HR), 2.40; 95% confidence interval (CI), 1.18-4.85; p=0.015, target vessel revascularization (TVR): HR, 3.33; 95% CI, 1.69-6.58; p=0.001, non-TVR: HR, 5.64; 95% CI, 1.90-16.6; p=0.002] and major adverse cardiac events (MACE; HR, 3.32; 95% CI, 1.92-5.73; p<0.001) were significantly higher in the RAF group than the CF group. However, the 3-year incidences of death and myocardial infarction were not different between the two groups.

CONCLUSION

RAF following index PCI with DES in AMI patients was associated with increased incidences of revascularization and MACE. Therefore, CF seems warranted for asymptomatic patients after PCI for AMI.

Everolimus eluting stent vs first generation drug-eluting stent in primary angioplasty: A pooled patient-level meta-analysis of randomized trials

BACKGROUND

Several concerns have emerged about the higher risk of very late stent thrombosis (ST) with first generation drug-eluting stent (DES) especially among STEMI patients. Newer generation DES has demonstrated to reduce ST at mid-term follow-up. Therefore, the aim of the present study is to perform an individual patient's data meta-analysis of trials comparing 1st generation DES vs. 2nd generation DES (everolimus-eluting stent, EES) in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI.

METHODS

We performed a formal search of electronic databases (MEDLINE and CENTRAL) and scientific session presentations from January 2010 to June 2016. We included all completed randomized trials comparing 1st vs. EES for patient presenting with STEMI.

RESULTS

Individual patients data were obtained from 3 trials, including a total of 1581 patients (686 or 43.4% randomized to 1st generation DES and 895 or 56.4% randomized to EES). At long-term follow-up (1584±588days), EES did not significantly reduce mortality (7.8.% vs 11.7%, HR [95%CI]=0.77 [0.52, 1.13], p=0.18, p_{heterogeneity}=0.93), cardiac mortality (6.2% vs 7.6%, HR [95%CI]=0.90 [0.56, 1.44], p=0.65, p_{heterogeneity}=0.85), and reinfarction (8.1% versus 11.2%, respectively; HR [95%CI]=0.74 [0.51, 1.07], p=0.11, p_{heterogeneity}=0.52). However, EES significantly reduced the occurrence of ST (3.4% versus 6.1% respectively, HR [95%CI]=0.56 [0.32, 0.97], p=0.04, p_{heterogeneity}=0.42) and target vessel revascularization (TVR) (14.2% versus 20.1%; HR [95%CI]=0.63 [0.42, 0.96], p=0.03, p_{heterogeneity}=0.55). Landmark analysis showed more consistent benefits in ST with EES within 1year, whereas benefits in TVR were mostly observed later than 1year.

CONCLUSIONS

The present pooled patient-level meta-analysis demonstrates that among STEMI patients undergoing primary PCI, EES as compared to 1st generation DES is associated with a significant reduction in ST and TVR at long-term follow-up.

Staged versus One-Time Complete Revascularization with Percutaneous Coronary Intervention in STEMI Patients with Multivessel Disease: A Systematic Review and Meta-Analysis

INTRODUCTION

In patients with acute ST-elevation myocardial infarction (STEMI), the preferred intervention is percutaneous coronary intervention (PCI).Whether staged PCI (S-PCI) or one-time complete PCI (MV-PCI) is more beneficial and safer in terms of treating the non-culprit vessel during the primary PCI procedure is unclear. We performed a meta-analysis of all randomized and non-randomized controlled trials comparing S-PCI with MV-PCI in patients with acute STEMI and MVD.

METHODS

Studies of STEMI with multivessel disease receiving primary PCI were searched in PUBMED, EMBASE and The Cochrane Register of Controlled Trials from January 2004 to December 2014. The primary end points were long-term rates of major adverse cardiovascular events and their components-mortality, reinfarction, and target-vessel revascularization. Data were combined using a fixed-effects model.

RESULTS

Of 507 citations, 10 studies (4 randomized, 6 nonrandomized; 820 patients, 562 staged PCI and 347 one-time, complete multi-vessel PCI) were included. S-PCI compared to MV-PCI significantly reduced mortality both long-term (OR 0.44, 95% CI 0.29-0.66, P<0.0001, I2 = 0%) and short-term (OR 0.23, 95% CI 0.1-0.51, P = 0.0003, I2 = 0%). There was a trend toward reduced risk of MACE with s-PCI compared with MV-PCI (OR 0.83, 0.62-1.12, P = 0.22, I2 = 0%). No difference between S-PCI and MV-PCI was observed in reinfarction (OR 0.97, 0.61-1.55, P = 0.91, I2 = 0%), or target vessel revascularization (OR1.17, 95% CI 0.81-1.69, P = 0.40, I2 = 8%).

CONCLUSIONS

The staged strategy for non-culprit lesions improved short- and long-term survival and should remain the standard approach to primary PCI in patients with STEMI; one-time complete multivessel PCI may be associated with greater mortality risk. However, additional large, randomized trials are required to confirm the optimal timing of a staged procedure on the non-culprit vessel in STEMI.

Acute myocardial infarction

Acute myocardial infarction has traditionally been divided into ST elevation or non-ST elevation myocardial infarction; however, therapies are similar between the two, and the overall management of acute myocardial infarction can be reviewed for simplicity. Acute myocardial infarction remains a leading cause of morbidity and mortality worldwide, despite substantial improvements in prognosis over the past decade. The progress is a result of several major trends, including improvements in risk stratification, more widespread use of an invasive strategy, implementation of care delivery systems prioritising immediate revascularisation through percutaneous coronary intervention (or fibrinolysis), advances in antiplatelet agents and anticoagulants, and greater use of secondary prevention strategies such as statins. This seminar discusses the important topics of the pathophysiology, epidemiological trends, and modern management of acute myocardial infarction, focusing on the recent advances in reperfusion strategies and pharmacological treatment approaches.

The History of Primary Angioplasty and Stenting for Acute Myocardial Infarction

The evolution of the management of acute myocardial infarction (MI) has been one of the crowning achievements of modern medicine. At the turn of the twentieth century, MI was an often-fatal condition. Prolonged bed rest served as the principal treatment modality. Over the past century, insights into the pathophysiology of MI revolutionized approaches to management, with the sequential use of surgical coronary artery revascularization, thrombolytic therapy, and percutaneous coronary intervention (PCI) with primary coronary angioplasty, and placement of intracoronary stents. The benefits of prompt revascularization inspired systems of care to provide rapid access to PCI. This review provides a historical context for our current approach to primary PCI for acute MI.

Long-term outcomes of biodegradable versus durable polymer drug-eluting stents in patients with acute ST-segment elevation myocardial infarction: a pooled analysis of individual patient data from three randomised trials

AIMS

Arterial plaque rupture and thrombus characterise ST-elevation myocardial infarction (STEMI) and may aggravate delayed arterial healing following durable polymer drug-eluting stent (DP-DES) implantation. Biodegradable polymer (BP) may improve biocompatibility. We compared long-term outcomes in STEMI patients receiving BP-DES vs. durable polymer sirolimus-eluting stents (DP-SES).

METHODS AND RESULTS

We pooled individual patient-level data from three randomised clinical trials (ISAR-TEST-3, ISAR-TEST-4 and LEADERS) comparing outcomes from BP-DES with DP-SES at four years. The primary endpoint (MACE) comprised cardiac death, MI, or target lesion revascularisation (TLR). Secondary endpoints were TLR, cardiac death or MI, and definite or probable stent thrombosis. Of 497 patients with STEMI, 291 received BP-DES and 206 DP-SES. At four years, MACE was significantly reduced following treatment with BP-DES (hazard ratio [HR] 0.59, 95% CI: 0.39-0.90; p=0.01) driven by reduced TLR (HR 0.54, 95% CI: 0.30-0.98; p=0.04). Trends towards reduction were seen for cardiac death or MI (HR 0.63, 95% CI: 0.37-1.05; p=0.07) and definite or probable stent thrombosis (3.6% vs. 7.1%; HR 0.49, 95% CI: 0.22-1.11; p=0.09).

CONCLUSIONS

In STEMI, BP-DES demonstrated superior clinical outcomes to DP-SES at four years. Trends towards reduced cardiac death or myocardial infarction and reduced stent thrombosis require corroboration in specifically powered trials.

Safety and feasibility of a PAclitaxel-eluting balloon angioplasty in Primary Percutaneous coronary intervention in Amsterdam (PAPPA): one-year clinical outcome of a pilot study

AIMS

In primary percutaneous coronary intervention (PPCI), stenting has been shown to reduce the need for repeat target lesion revascularisation (TLR) compared to balloon angioplasty alone, but did not result in a reduction of recurrent myocardial infarction (MI) or cardiac death. Meanwhile, stent-related adverse events such as stent thrombosis continue to be of concern. Our aim was to evaluate the safety and feasibility of drug- coated balloon (DCB) angioplasty without stenting in PPCI.

METHODS AND RESULTS

One hundred patients presenting with ST-elevation MI were prospectively enrolled in this pilot study. They underwent PPCI with DCB angioplasty; additional stenting was allowed only in case of type C to F coronary dissection or residual stenosis >50%. All patients were treated with i.v. bivalirudin. The primary endpoint was the composite of cardiac death, recurrent MI and TLR. A total of 59 patients received treatment with DCB angioplasty alone, whereas additional stenting was required in 41 patients. One-year clinical follow-up was completed in 98 patients. A total of five major adverse cardiac events were reported (5%). Cardiac death was seen in two patients, while three patients underwent TLR.

CONCLUSIONS

This first study of a DCB angioplasty-only strategy in the setting of PPCI showed good one-year clinical results.

Clinical outcomes of second- versus first-generation drug-eluting stents in patients with acute myocardial infarction: a meta-analysis of randomized controlled trials

INTRODUCTION

It remains unclear whether the clinical outcomes of patients with acute myocardial infarction (AMI) receiving second- and first-generation drug-eluting stents (DES) are identical. The study aimed to investigate the differences in clinical utility between the two generations of DES in these specific subjects by a meta-analysis.

MATERIAL AND METHODS

We systemically searched PubMed and EMBASE databases and the Cochrane Library up until January 2013. Randomized trials, which compared clinical outcomes of second-generation DES (everolimus- (EES) or zotarolimus-eluting stents (ZES)) with first-generation DES (sirolimus- or paclitaxel-eluting stents) in patients with AMI were included.

RESULTS

Five trials with 1720 AMI subjects were included in the meta-analysis. Pooled analysis demonstrated a trend toward lower incidence of stent thrombosis with the second-generation DES relative to the first-generation one (risk ratio (RR), 0.53; 95% confidence intervals (CI): 0.25-1.13; p = 0.10). However, the second-generation DES did not offer a significant advantage over the first-generation DES in reducing the incidence of target lesion revascularization (TLR) (RR = 1.73; 95% CI: 0.83-3.64; p = 0.15), major adverse cardiac events (MACEs) (RR = 0.97; p = 0.90), or all-cause death (RR = 1.00; p = 1.0). In addition, in elderly patients the second-generation DES seemed to reduce the occurrence of MACEs (RR = 0.65; p = 0.10) and stent thrombosis (RR = 0.40; p = 0.08), and the second-generation EES showed a potential benefit in lowering the MACE rate (RR = 0.55; p = 0.06).

CONCLUSIONS

The second-generation DES appeared to lower the risk of stent thrombosis in AMI patients. There might be a lower incidence of MACEs associated with the second-generation EES.

Long-term outcomes of drug-eluting versus bare-metal stent for ST-elevation myocardial infarction

BACKGROUND

Long-term outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI) remain uncertain.

OBJECTIVE

To investigate long-term outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

We performed search of MEDLINE, EMBASE, the Cochrane library, and ISI Web of Science (until February 2013) for randomized trials comparing more than 12-month efficacy or safety of DES with BMS in patients with STEMI. Pooled estimate was presented with risk ratio (RR) and its 95% confidence interval (CI) using random-effects model.

RESULTS

Ten trials with 7,592 participants with STEMI were included. The overall results showed that there was no significant difference in the incidence of all-cause death and definite/probable stent thrombosis between DES and BMS at long-term follow-up. Patients receiving DES implantation appeared to have a lower 1-year incidence of recurrent myocardial infarction than those receiving BMS (RR = 0.75, 95% CI 0.56 to 1.00, p= 0.05). Moreover, the risk of target vessel revascularization (TVR) after receiving DES was consistently lowered during long-term observation (all p < 0.01). In subgroup analysis, the use of everolimus-eluting stents (EES) was associated with reduced risk of stent thrombosis in STEMI patients (RR = 0.37, p=0.02).

CONCLUSIONS

DES did not increase the risk of stent thrombosis in patients with STEMI compared with BMS. Moreover, the use of DES did lower long-term risk of repeat revascularization and might decrease the occurrence of reinfarction.

Drug-eluting stents in patients with anterior STEMI undergoing primary angioplasty: a substudy of the DESERT cooperation

BACKGROUND

Several concerns have emerged on the higher risk of in-stent thrombosis after drug-eluting stent (DES) implantation, especially in the setting of STEMI patients. Few data have even been reported in high-risk patients, such as those with anterior MI. Therefore this represents the aim of the current study.

METHODS

The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL). We examined all completed randomized trials of DES for STEMI. The following key words were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, stenting, DES, sirolimus-eluting stent (SES), Cypher, paclitaxel-eluting stent (PES), Taxus. No language restrictions were enforced.

RESULTS

Individual patient's data were obtained from 11 out of 13 trials, including a total of 2,782 patients with anterior MI [1,739 or 62.5% randomized to DES and 1,043 or 37.5% randomized to bare-metal stent (BMS)]. At long-term follow-up, no significant benefit was observed with DES as compared to BMS in terms of mortality [9.8 vs 10.9%, HR (95% CI) = 0.81 (0.61, 1.07), p = 0.13, p heterogeneity = 0.18], reinfarction [8.8 vs 6.4%, respectively; HR (95% CI) = 1.14 (0.80, 1.61), p = 0.47, p heterogeneity = 0.82], and stent thrombosis [5.6 vs 5%, OR (95% CI) = 0.88 (0.59, 1.30), p = 0.51, p heterogeneity = 0.65], whereas DES was associated with a significant reduction in terms of target-vessel revascularization (TVR) [13.7 vs 23.4%; OR (95% CI) = 0.56 (0.46, 0.69), p < 0.0001, p het = 0.81] that was observed at both early (within 1 year) [7 vs 14.7%, HR (95% CI) = 0.56 (0.46, 0.69), p < 0.0001, p het = 0.81] and late (>1 year) follow-up [7.2 vs 9%, HR (95% CI) = 0.67 (0.47, 0.96), p = 0.03, p het = 0.96].

CONCLUSIONS

This study showed that among patients with anterior STEMI undergoing primary angioplasty, SES and PES, as compared to BMS, are associated with a significant reduction in TVR at long-term follow-up. No concerns were found with the use of first-generation DES in terms of mortality.

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.

Cost effectiveness of drug-eluting stents as compared with bare metal stents in patients with coronary artery disease

The aim of this study was to estimate the incremental cost effectiveness of replacing bare metal stents (BMS) by drug-eluting stents (DES) when using trial data and registry data. We developed a Markov model (model of cost effectiveness of coronary artery disease) in which 60-year-old patients started by undergoing percutaneous coronary intervention for acute or subacute coronary artery disease. The patients are followed until death or 100 years of age. Data on the occurrence of events (revascularization, acute myocardial infarction, and death) were based on Scandinavian registry data. Separate analyses were conducted with data on effectiveness based on randomized controlled trials and patient registries. On using trial data, it was found that sirolimus-eluting stents (SES) yield 0.003 greater life expectancy and $3300 lower costs than do BMS (dominant strategy). Paclitaxel-eluting stents (PES) yield 0.148 more life years than do SES at additional lifetime costs of $2800 ($21,400 per life year gained). On using registry data, the cost per life year gained was found to be $4900 when replacing BMS with DES. Probabilistic sensitivity analyses, on the other hand, indicate that PES only has a 50%-75% probability of being cost effective, regardless of the type of effectiveness data. DESs are cost effective with current willingness to pay for life year gains. Whether PES or SES is the most effective DES remains uncertain.

Impact of age on long-term outcome after primary angioplasty with bare-metal or drug-eluting stent (from the DESERT cooperation)

Despite mechanical reperfusion, elderly patients with ST-segment elevation myocardial infarction (STEMI) still experience unsatisfactory outcomes. Drug-eluting stents (DES) have significantly reduced target-vessel revascularization (TVR), but concerns have emerged about the higher risk of late stent thrombosis, which may be more pronounced in elderly patients. Therefore, the aim of this study was to evaluate the impact of age on outcome in patients with STEMI who underwent primary angioplasty with bare-metal stents (BMS) or DES. Our population comprised 6,298 patients who underwent primary angioplasty and stent implantation included in the Drug-Eluting Stent in Primary Angioplasty (DESERT) Cooperation database. Age was significantly associated with female gender (p <0.001), diabetes (p <0.001), hypertension (p <0.001), previous myocardial infarction (MI; p <0.001), ischemia time (p <0.001), and anterior MI (p <0.001) but inversely related to smoking (p <0.001). Elderly patients most often had infarct-related artery located in the descending artery (p = 0.014) and impaired postprocedural thrombolysis in myocardial infarction flow (p <0.001). Elderly patients were less often on clopidogrel at follow-up. At long-term follow-up, age was associated with a higher rate of death (hazard ratio [95% confidence interval] = 2.17 [1.97 to 2.39], p <0.0001), whereas no impact was observed on reinfarction (p = 0.36), stent thrombosis (p = 0.84), and TVR (p = 0.54). These results were confirmed in patients receiving both BMS and DES. The impact of age on mortality was confirmed after correction for baseline confounding factors (gender, diabetes hypertension, hypercholesterolemia, smoking, ischemia time, anterior MI, infarct-related artery location, and postprocedural thrombolysis in myocardial infarction 3 flow; adjusted hazard ratio [95% confidence interval] = 2.13 [1.78 to 2.56], p <0.001). In conclusion, this study shows that in patients with STEMI who underwent primary angioplasty, age is independently associated with higher mortality, observed with both BMS and DES, whereas no impact was observed on the rate of reinfarction, stent thrombosis, and TVR.

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.

Pharmaco-mechanic antithrombotic strategies to reperfusion of the infarct-related artery in patients with ST-elevation acute myocardial infarctions

Primary percutaneous coronary intervention is the best treatment of patients with ST elevation myocardial infarction (STEMI). When managing a STEMI patient, our approach must be rapid and aggresive in order to interrupt the pathological process of thrombus formation and stabilization. The therapy must be initiated prior to angiography (pretreatment), continued during the procedure (periprocedural), recovery phase (in-hospital), and follow-up. The treatment strategies resulting in thrombus dissolution/extraction have focused on optimization of both pharmacological and interventional therapies. At present, there is no optimal evidence-based approach to all patients with STEMI, and the treatment of these patients needs to be modified with respect to the risk profile, availability of medical resources, and our experience. In this review, we summarize current pharmacological and interventional strategies used in the setting of STEMI and discuss potential benefits of novel dosing regimens and combinations of drugs and techniques.

Relationship between biomarkers and subsequent clinical and angiographic restenosis after paclitaxel-eluting stents for treatment of STEMI: a HORIZONS-AMI substudy

Drug-eluting stents (DES) reduce the incidence of in-stent restenosis (ISR) after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). Whether the use of biomarkers might be of utility to identify patients who remain at risk for DES ISR after primary PCI has never been examined. A total of 26 biomarkers were measured at enrollment and 30 days and analyzed at a central core laboratory in 501 STEMI patients from the HORIZONS-AMI trial. All patients underwent primary PCI with the TAXUS paclitaxel-eluting stent (PES), were scheduled for routine angiographic follow-up at 13 months, and were followed for 3 years. Mean in-stent late-loss was 0.28 ± 0.57 mm, and target lesion revascularization (TLR) at 3 years occurred in 9.1 % of patients. Low levels of interleukin-6 (IL-6) and placental growth factor (PLGF) at admission were associated with both higher in-stent late loss and ischemia-driven TLR. Additionally, low admission levels of cardiotrophin-1 (CT-1) were associated with higher rates of ischemia-driven TLR. At 30-day follow-up lower values of IL-1ra (IL-1ra), matrix metalloproteinase 9 (MMP9), and myeloperoxidase (MPO), and a decline relative to admission in IL-1ra, monocyte chemotactic protein-1 (MCP-1), and MMP9 were associated with higher in-stent late loss. Low values of IL-6 at 30 days were also associated with ischemia-driven TLR. After multivariate adjustment, only MPO at 30 days and a decline of MCP-1 between admission and 30 days were associated with in-stent late loss, and only CT-1 was associated with TLR. MPO at 30 days and a decline of MCP-1 between admission and 30 days were independently associated with in-stent late loss, and CT-1 was associated with TLR. Additional studies to confirm and validate the utility of these biomarkers are warranted.

Long-term safety and efficacy of sirolimus- and Paclitaxel-eluting stents in patients with acute myocardial infarction: four-year observational study

Background and Objectives

The comparison of long-term clinical effects between Sirolimus-eluting stent (SES) and Paclitaxel-eluting stents (PES) for treatment of acute myocardial infarction (AMI) remains unclear. Seeking to clarify this issue, we performed a retrospective analysis to evaluate four-year clinical outcomes of SES compared to PES treated AMI patients.

Subjects and Methods

From January 2004 to August 2006, all patients with acute ST-segment elevation myocardial infarction and acute non-ST segment elevation myocardial infarction who underwent percutaneous coronary intervention (PCI) by implantation of either SES or PES were enrolled. The occurrences of cardiac and non-cardiac deaths, recurrent infarction, target vessel revascularization (TVR) and stent thrombosis were analyzed. The composite end points of these major adverse cardiac events (MACE) were also analyzed.

Results

During the study period, a total of 668 AMI patients had visited, of which 522 patients (299 with SES and 223 with PES) were enrolled. During the four-year clinical follow-up, both groups showed similar occurrences of non-cardiac death (14.6±2.2% vs. 18.3±3.0%, p=0.26); cardiac death (6.8±1.52% vs. 11.2±2.6%, p=0.39); re-infarction (3.3±1.1% vs. 6.4±1.8%, p=0.31); and stent thrombosis (3.2±1.1% vs. 5.4±1.7%, p=0.53). However, occurrences of TVR {4.0±1.2% vs. 10.0±3.0%, hazard ratio (HR)=0.498, 95% confidence interval (CI)=0.257-0.967, p=0.039} and MACE (19.4±2.5% vs. 29.4±3.5%, HR=0.645, 95% CI=0.443-0.940, p=0.021) were significantly lower in the SES population.

Conclusion

In AMI patients treated with either SES or PES implantation, the former had a significantly lower risk of TVR and MACE during four-year clinical follow-up. Rates of death, cardiac death or recurrent infarction, and stent thrombosis were similar.

Comparison of zotarolimus-eluting stents versus sirolimus-eluting stents versus paclitaxel-eluting stents for primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction: results from the Korean Multicentre Endeavor (KOMER) acute myocardial infarction (AMI) trial

AIMS

The aim of this study was to compare the efficacy and safety of zotarolimus-eluting stents (ZES), sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

This study was a prospective, single-blind, multicentre, randomised trial. The primary endpoint was major adverse cardiac events (MACE) at 12 months post-procedure, defined as cardiac death, recurrent myocardial infarction (MI), or ischaemia-driven target lesion revascularisation (TLR). An angiographic substudy was performed at nine months among 348 patients. From October 2006 to April 2008, 611 patients with STEMI undergoing primary PCI were randomly assigned to treatment with ZES (n=205), SES (n=204), or PES (n=202). The cumulative incidence of MACE was 5.9% in the ZES group, 3.4% in the SES group and 5.7% in the PES group at 12-month follow-up (p=0.457). There was a trend towards a lower rate of ischaemia-driven TLR at 12- (p=0.092) and 18-month (p=0.080) follow-up in the SES group compared to the ZES and PES groups. No difference was observed in rates of cardiac death, recurrent MI and combined death and/or recurrent MI among three groups at 12- and 18-month follow-up. The rate of stent thrombosis was similar among the three groups (2.0% in each group, p=1.000).

CONCLUSIONS

As compared with SES and PES, the use of ZES in patients with STEMI undergoing primary PCI, showed similar rates of MACE, cardiac death and recurrent MI at 12 and 18 months. There was a trend towards a higher rate of TLR with ZES or PES compared to SES.

Rodriguez A, Bramucci E, Moreno R, Piva T, Sheiban I, Pasquetto G, Prati F, Nazzaro MS, Ferrari R, Valgimigli M. Sex-specific benefits of sirolimus-eluting stent on long-term outcomes in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: insights from the Multicenter Evaluation of Single High-Dose Bolus Tirofiban Versus Abciximab With Sirolimus-Eluting Stent or Bare-Metal Stent in Acute Myocardial Infarction Study trial

OBJECTIVES

We assessed the relation between female sex and sirolimus-eluting stent (SES) use on long-term outcomes in acute myocardial infarction.

BACKGROUND

There are no data on sex-specific differences in long-term benefit of SES use compared with bare-metal stent (BMS) use among patients undergoing primary percutaneous coronary interventions.

METHODS

We performed a post hoc analysis of the MULTISTRATEGY trial. Hazard ratios (HRs) of events with 95% CI for sex and stent type were computed using Cox proportional regression with adjustment for confounders.

RESULTS

A total of 744 patients, 64 years old (55-73 years old), 179 (24.1%) women, were enrolled. After a follow-up of 1,080 days, SES use was associated with a significant reduction of major adverse cardiovascular events, that is, the composite of all-cause death, reinfarction, or clinically driven target vessel revascularization (TVR) (13.9% vs 23.6%, adjusted HR 0.62, 95% CI 0.41-0.94, P = .026) and of TVR (6.1% vs 15.1%, adjusted HR 0.35, 95% CI 0.19-0.63, P < .001) in men. Conversely, SES use was not associated to a better outcome among women (major adverse cardiovascular events 21.9% in SES vs 18.2% in the BMS group, adjusted HR 1.27, 95% CI 0.53-3.02, P = .59; TVR 6.6% vs 9.1%, adjusted HR 0.62, 95% CI 0.17-2.21, P = .46).

CONCLUSIONS

In this analysis, the clinical benefit of SES use, over BMS, at 3-year follow-up was restricted to men and was not observed among women.

Outcomes of drug-eluting stents compared to bare-metal stents in ST-segment elevation acute myocardial infarction

INTRODUCTION

Primary percutaneous coronary intervention (PPCI) has become the treatment of choice in patients with ST-segment elevation myocardial infarction (STEMI). Drug-eluting stents (DES) reduce restenosis compared to bare-metal stents (BMS) but there is conflicting data concerning their use in the setting of STEMI. We aimed to evaluate the influence of the type of stent on the outcomes of PPCI.

METHODS

This was a single-center longitudinal study including 213 consecutive patients (76% men, mean age 60 +/- 12 years) with STEMI undergoing PPCI between 2003 and 2007, divided into two groups: BMS (43.7%) and DES (56.3%). We assessed clinical and demographic features as well as angiographic and electrocardiographic signs of myocardial reperfusion. The composite outcome of death, myocardial infarction (MI) or target-lesion revascularization (TLR) was evaluated.

RESULTS

At a median follow-up of 26 months there were no differences in the composite outcome of death/MI/TLR (BMS 18.3% vs DES 15.8%) or in the incidence of stent thrombosis. Angiographic results of the procedure were also similar. Independent predictors of the composite outcome were age (HR = 1.06, 95% CI [1 .02-1.11], left anterior descending artery as infarct-related vessel (HR = 2.69, 95% CI [1.17-6.19]) and use of glycoprotein IIb/IIIa inhibitors (HR = 0.33, 95% CI [0.13-0.83]).

CONCLUSIONS

There was no benefit in angiographic outcomes or major cardiac events after treatment with drug-eluting stents compared to bare-metal stents in this group of patients with STEMI.

Safety and benefits of protamine administration to revert anticoagulation soon after coronary angioplasty. A meta-analysis

Recent studies suggests that bleeding complications are associated with worse clinical outcome and survival among patients undergoing coronary angioplasty. Thus, in the last years increasing interests have been focused on strategies to prevent bleeding complications. The administration of protamine after coronary stenting for early sheath removal seems very attractive to minimize local and systemic bleeding complications. Thus, the aim of the current study is to perform a meta-analysis of randomized and non-randomized trials evaluating the benefits and safety of protamine administration after coronary angioplasty. The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL) from January 1990 to December 2009. The following key words were used: coronary angioplasty, primary angioplasty, coronary stenting, protamine, heparin neutralization, bleeding complications. Primary endpoints were death and major bleeding complications, respectively. Secondary endpoint was myocardial infarction. A total of 5 trials, 2 randomized and 3 non randomized were included in the meta-analysis, involving 6,762 patients (4,913 or 72.6% in the protamine group and 1,949 or 27.4% in the standard group). Protamine administration was not associated with difference in short-term mortality (2.8% vs. 2.7%, OR [95% CI] = 0.97 [0.69-1.37], P = 0.88, p(het) = 1.0), but with a significant reduction in major bleeding complications (2.4% vs. 4.1%, OR [95% CI] = 0.51 [0.37-0.69], P < 0.0001, p(het) = 0.53, NNT = 58.8). No difference was observed myocardial infarction (0.9% vs. 0.8%, OR [95% CI] = 1.14 [0.63-2.07], P = 0.66, p(het) = 0.89). This meta-analysis shows that protamine administration after percutaneous coronary intervention seems to be safe and associated with a significant reduction in major bleeding complications. Pending the results of larger randomized trials, its use may be considered after coronary angioplasty.

Three-year clinical outcome with the Endeavor™ zotarolimus-eluting stent in primary percutaneous coronary intervention for ST elevation myocardial infarction: the Endeavor™ primary PCI study (E-PPCI)

Primary percutaneous coronary intervention (PPCI) is superior to thrombolysis in STEMI (ST segment elevation myocardial infarction) patients. Data on late stent thrombosis (ST) have raised concerns regarding the use of drug-eluting stents during PPCI. We report the first 3-year clinical evaluation of the zotarolimus-eluting stent (ZES) in patients undergoing PPCI for STEMI, a single-center, prospective cohort study of consecutive patients admitted with STEMI. All underwent PPCI within 12 hours of symptoms; each received one or more ZES in one or more target lesions. All patients received aspirin 300 mg, clopidogrel 600 mg, abciximab, and unfractionated heparin. A total of 102 STEMI patients (76 male, mean 62 years) received 162 ZES (mean 1.6 stents/patient). Median call-to-balloon time was 123 (102-152) minutes. Thirty-day combined major adverse cardiovascular event (MACE) rate was 3.9% (n = 4). Subacute ST occurred in 2 patients (1.96%). Combined MACE rates at 12 months and 3 years were 7.8% (n = 8) and 13.7% (n = 14). Late ST occurred in 1 patient (1%) with no occurrence of very late ST. This is the first 3-year report of the use of the ZES in an unselected, consecutive PPCI population. Overall 3-year incidence of MACE and target lesion revascularization (5.9%) was low, and was comparable to that seen with sirolimus- and paclitaxel-eluting stents in randomized controlled trials. At 3 years there was no occurrence of very late ST.

How safe and how good are drug-eluting stents?

Percutaneous transluminal coronary angioplasty revolutionized therapy for coronary artery disease. This early promise of a viable alternative to surgical treatment of coronary artery disease was thwarted by the high rates of angiographic restenosis. The advent of stenting reduced the rates of restenosis, although it was hindered by the new problem of in-stent restenosis. It was demonstrated that in-stent restenosis was the result of a new pathology in the form of neointimal hyperplasia, which was a maladaptive healing response to bare-metal stent implantation. Recently, the introduction of drug-eluting stents (DES) technology has offered a new solution to the problem of restenosis. Current evidence suggests that although DES have reduced restenosis rates, important concerns have been raised regarding increased stent thrombosis, myocardial infarction and death. The purpose of this article is to examine the efficacy and safety data of DES as highlighted in recent publications and to further discuss the biomolecular mechanisms of accelerated endothelization and stent thrombosis. In addition, we will examine some of the newer stent technologies available.

Biolimus-eluting biodegradable polymer-coated stent versus bare metal stent in acute ST-elevation and non-ST elevation myocardial infarction: Justification for biodegradable polymer-coated stent in acute coronary syndrome (JANICE) registry

AIMS

We evaluated the efficacy and safety of a biolimus- eluting biodegradable polymer-coated stent (BES) in patients with ST-segment elevation and non ST-segment elevation acute myocardial infarction (AMI).

METHODS AND RESULTS

This was an observational study involving a single centre patient registry. We compared the rates of cardiac death, myocardial infarction, target vessel revascularization (TVR) and composite end point of cardiac death and myocardial infarction at 24 months in 106 patients who received BES versus 94 patients who received an otherwise similar bare metal stent (BMS) during percutaneous coronary intervention for AMI. There was no significant difference in the rate of cardiac death (0.9% versus 7.4%; P = 0.09), myocardial infarction (4.7% versus 3.2%; P = 0.69), stent thrombosis (0.9% versus 3.2%; P = 0.30) or cardiac death and myocardial infarction (5.7% versus 10.6%; P = 0.30) between the two groups. The rate of TVR was significantly higher in the BMS group (1.9% versus 8.5%; P = 0.04), with patients receiving BMS being four times more likely to require TVR.

CONCLUSION

The use of BES in selected patients with AMI appears to be safe and is associated with significantly reduced rate of TVR, when compared with an otherwise similar BMS.

Drug-eluting stents versus bare-metal stents in acute myocardial infarction: A systematic review and meta-analysis

Objectives: Recent concerns have been raised for the safety after drug-eluting stents (DES) implantation compared with the use of bare-metal stents (BMS) in patients with ST-elevation acute myocardial infarction (STEMI). The objective of this study was to estimate the relative impact of DES versus BMS on mortality, myocardial infarction (MI), target vessel revascularization (TVR), and stent thrombosis (ST) in STEMI patients by performing comprehensive meta-analyses of randomized controlled trials (RCTs) and observational studies.

Methods: We performed an electronic search and manual search of studies presented through September 2009, without language restrictions. An approach of “using systematic reviews” was used. Two independent reviewers extracted prespecified data from each study. A random-effects model was used to combine trials and to perform stratified analyses based on study designs and the duration of follow-up.

Results: Fourteen RCTs were identified (N = 7,654). Compared with BMS, DES significantly reduced TVR (risk ratio [RR], 0.48; 95 percent confidence interval [CI], 0.41–0.56) and MI (RR, 0.77; 95 percent CI, 0.61–0.97), without increasing mortality (RR, 0.88; 95 percent CI, 0.70–1.10) and ST (RR, 0.93; 95 percent CI, 0.72–1.21). Among 35 observational studies (N = 44,849), the use of DES was associated with a significant reduction in mortality (RR, 0.85; 95 percent CI, 0.79–0.91) and TVR (RR, 0.61; 95 percent CI, 0.48–0.77). MI and ST were significantly lower in the DES group within 1-year follow-up, but there were no differences within 2 years of follow-up. There was no evidence of statistical heterogeneity and publication bias.

Conclusions: These data in aggregate suggest that using DES in STEMI patients is safe and efficacious, but there are differences between RCT and observational data comparing DES and BMS.

A meta-analysis of randomized trials on clinical outcomes of paclitaxel-eluting stents versus bare-metal stents in ST-segment elevation myocardial infarction patients

A meta-analysis was performed to address the efficacy and safety of paclitaxel-eluting stent (PES) in ST-segment elevation myocardial infarction (STEMI) patients. A systematic literature search was conducted to identify all randomized clinical trials in mortality, recurrent myocardial infarction (rMI), repeat revascularization (RR), and stent thrombosis (ST). A total of 4190 STEMI patients were enrolled in six randomized trials comparing PES with bare-metal stent (BMS). The pooled repeat revascularization rate was 5.7% in PES group, significantly lower than 10.0% in BMS group with an odds ratio (OR) of 0.56, 95% confidence interval (CI) [0.44, 0.72] (P<0.00001). No significant difference was found between PES and BMS groups in mortality at one year after the indexing procedure (3.9% vs. 5.1%, OR 0.88, 95% CI [0.63, 1.21], P=0.42). Similarly, rMI rate did not differ significantly between the two groups (3.4% vs. 4.1%, OR 0.80, 95% CI [0.56, 1.13], P=0.21). PES was also associated with the comparable pooled rate of definite stent thrombosis with BMS (2.3% vs. 2.4%, OR 0.81, 95% CI [0.52, 1.26], P=0.35). The results show that PES improved clinical outcomes in STEMI patients with a decreased need for repeat revascularization and no concerns for safety.