As time goes by: current status and future directions in the controversy over stenting

Effects of Ticagrelor versus Clopidogrel in Patients with Coronary Bifurcation Lesions Undergoing Percutaneous Coronary Intervention

Background

Percutaneous treatment of coronary bifurcation lesions can potentially lead to higher risk of ischemic events than the nonbifurcation ones, thus calling for further optimization of dual antiplatelet therapy (DAPT). This study aimed to compare the clinical outcomes from ticagrelor and clopidogrel in bifurcation lesions patients undergoing percutaneous coronary intervention (PCI).

Methods

We performed a retrospective cohort study in patients with coronary bifurcation lesions. A total of 553 patients discharged on ticagrelor or clopidogrel combined with aspirin were recruited for 1-year follow-up. The incidences of primary endpoint (major adverse cardiovascular event [MACE]: a composite of cardiac death, myocardial infarction [MI] or stroke), secondary endpoints (the individual component of the primary endpoint or definite/probable stent thrombosis), and major bleeding (Bleeding Academic Research Consortium [BARC]≥3 bleeding events) were evaluated. To minimize the selection bias, a propensity score-matched population analysis was also conducted.

Results

The risks of both primary endpoint (8.15% and 12.01% for the ticagrelor and clopidogrel groups, respectively; adjusted hazards ratio [HR]: 0.488, 95% confidence interval [CI]: 0.277-0.861, P=0.013) and MI (4.44% and 8.48% for the ticagrelor and clopidogrel groups, respectively; adjusted HR: 0.341, 95% CI: 0.162-0.719, P=0.005) were significantly reduced in the ticagrelor group as compared with those of the clopidogrel counterpart, whereas the risk of major bleeding was comparable (2.96% and 2.47% for the ticagrelor and clopidogrel groups, respectively; adjusted HR: 0.972, 95% CI: 0.321-2.941, P=0.960). Propensity score-matched analysis confirmed such findings.

Conclusions

For patients with bifurcation lesions after PCI, ticagrelor treatment shows lower MACE and MI rates than the clopidogrel one, along with comparable major bleeding.

Functional Nanoarchitectures For Enhanced Drug Eluting Stents

Different strategies have been investigated to allow for optimum duration and conditions for endothelium healing through the enhancement of coronary stents. In this study, a nanoarchitectured system is proposed as a surface modification for drug eluting stents. Highly oriented nanotubes were vertically grown on the surface of a new Ni-free biocompatible Ti-based alloy, as a potential material for self-expandable stents. The fabricated nanotubes were self-grown from the potential stent substrate, which are also proposed to enhance endothelial proliferation while acting as drug reservoir to hinder Vascular Smooth Muscle Cells (VSMC) proliferation. Two morphologies were synthesized to investigate the effect of structure homogeneity on the intended application. The material was characterized by field-emission scanning electron microscope (FESEM), X-ray diffraction (XRD), Raman spectroscopy, energy dispersive X-ray spectroscopy (EDX), and X-ray photoelectron spectroscopy (XPS). Nanoindentation technique was used to study the mechanical properties of the fabricated material. Cytotoxicity and proliferation studies were performed and compared for the two fabricated nanoarchitectures, versus smooth untextured samples, using in-vitro cultured endothelial cells. Finally, the drug loading capacity was experimentally studied and further supported by computational modeling of the release profile.

A kinetic model for the integrated assessment of safety and efficacy in clinical trials

Regulatory agencies, professional societies, and clinical trialists commonly base judgments of treatment benefit on separate assessments of efficacy and safety. When separate assessments were compared with an integrated assessment using a kinetic model of a hypothetical randomized trial of antiplatelet agents in patients with acute coronary syndrome, the former showed treatment A to be superior to treatment B, whereas the latter showed treatment B to be superior to treatment A. In conclusion, comparative judgments regarding the balance between efficacy and safety depend on the model chosen for analysis; kinetic models are particularly suited to the integrated assessment of efficacy and safety relative to regulatory decisions, public policy, guideline development, and clinical care.

Pathological perspective of drug-eluting stent thrombosis

Although very late stent thrombosis (VLST) after drug-eluting stent (DES) implantation remains a major concern, the precise mechanisms have not been clarified. An association between late acquired incomplete stent apposition (ISA) and VLST of DES has been suggested by several intravascular ultrasound studies demonstrating very high prevalence of ISA in the setting of VLST. To clarify the pathological mechanisms of VLST, we investigated vascular responses of coronary arteries of VLST cases after DES implantation.

Is Stenting an Appropriate Therapy in Women Presenting with Acute Coronary Syndrome? A Pathologist's Perspective

It has been more than 3 decades since the introduction of percutaneous transluminal coronary angioplasty for the treatment of coronary artery disease, and the introduction of bare metal stents and drug-eluting stents (DES) has significantly improved clinical outcomes by decreasing rates of acute vessel closure and restenosis. This article reviews pathologic findings from male and female patients who had received coronary stents for acute coronary syndrome and died suddenly with or without complications of stent implantation, at early (<30 days) and late (>30 days) time points after DES implantation.

Acute myocardial infarction late following stent implantation: Incidence, mechanisms and clinical presentation

Acute myocardial infarction (AMI) can occur late following stent implantation with an incidence up to >6% at 3-4 years, with no difference between DES and BMS. AMI can originate either from the stented site or from disease progression at nonstented sites. Restenosis, against previous thoughts, can lead to AMI. Stent thrombosis occurs with similar overall frequency following DES and BMS implantations, although a higher very late stent thrombosis with DES has been observed. Dissimilar mechanisms between BMS and DES thrombosis are very likely, with impaired neointimal healing being the rule for DES but the exemption for BMS. The use of invasive imaging techniques is useful in elucidating the involved mechanism. Disease progression is a particularly important cause of AMI late post stenting. The angiographic study depicted stent failure and disease progression equally implicated in the AMI late post stenting. When the AMI underlying mechanism is stent thrombosis, it usually occurs earlier and more frequently presented as STEMI compared to the other causes of AMI. The AMI caused by restenosis is more often presented as nonSTEMI, while disease progression leads to AMI later than the other causes. Further research should address equally not only the stent related inadequacies but also disease progression as causes of the future AMI. Angiographic follow-up and intracoronary imaging seem the most appropriate methods to define the exact pathophysiologic mechanism responsible for the AMI post stenting.

Evolution of percutaneous coronary intervention in patients with diabetes: a report from the National Heart, Lung, and Blood Institute-sponsored PTCA (1985-1986) and Dynamic (1997-2006) Registries

OBJECTIVE

To evaluate the association of successive percutaneous coronary intervention (PCI) modalities with balloon angioplasty (BA), bare-metal stent (BMS), drug-eluting stents (DES), and pharmacotherapy over the last 3 decades with outcomes among patients with diabetes in routine clinical practice.

RESEARCH DESIGN AND METHODS

We examined outcomes in 1,846 patients with diabetes undergoing de novo PCI in the multicenter, National Heart, Lung, and Blood Institute-sponsored 1985-1986 Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry and 1997-2006 Dynamic Registry. Multivariable Cox regression models were used to estimate the adjusted risk of events (death/myocardial infarction [MI], repeat revascularization) over 1 year.

RESULTS

Cumulative event rates for postdischarge (31-365 days) death/MI were 8% by BA, 7% by BMS, and 7% by DES use (P = 0.76) and for repeat revascularization were 19, 13, and 9% (P < 0.001), respectively. Multivariable analysis showed a significantly lower risk of repeat revascularization with DES use when compared with the use of BA (hazard ratio [HR] 0.41 [95% CI 0.29-0.58]) and BMS (HR 0.55 [95% CI 0.39-0.76]). After further adjustment for discharge medications, the lower risk for death/MI was not statistically significant for DES when compared with BA.

CONCLUSIONS

In patients with diabetes undergoing PCI, the use of DES is associated with a reduced need for repeat revascularization when compared with BA or BMS use. The associated death/MI benefit observed with the DES versus the BA group may well be due to greater use of pharmacotherapy.

Clinician-patient discord: exploring differences in perspectives for discontinuing clopidogrel

BACKGROUND

Premature stopping of anti-platelet therapy has potentially fatal consequences for myocardial infarction (MI) patients who have received a drug-eluting stent (DES). Exploring multiple perspectives to identify contributing factors to the problem is essential.

AIM

We gained patient and clinician perspectives as to why MI patients prematurely stop anti-platelet therapy (clopidogrel) after DES implantation.

METHODS

This qualitative, descriptive study of DES-treated MI patients (n=22) and of clinicians (physicians and nurse practitioners; n=17) from multiple U.S. cities used content analysis of interview data. Findings across patients and clinicians were then compared to examine congruent and contrasting reasons for premature clopidogrel discontinuance.

FINDINGS

Patients frequently identified communication and education (e.g. unaware they should be taking clopidogrel, unaware of intended duration of therapy) as the primary reasons for having stopped. Patients rarely cited cost, while clinicians most commonly cited cost as a reason for premature stopping.

CONCLUSIONS

The discrepancy in perceptions of patients and clinicians as to the primary reason for early discontinuance suggests an important opportunity for improving persistence. Rather than focusing on the high costs of medications, something outside of their control, physicians should consider communicating more effectively the importance and intended duration of clopidogrel to their patients.

Nanomedicine for the reduction of the thrombogenicity of stent coatings

The treatment of patients with drug-eluting stents (DES) continues to evolve with the current emergence of DES technology that offers a combination of pharmacological and mechanical approaches to prevent arterial restenosis. However, despite the promising short-term and mid-term outcomes of DES, there are valid concerns about adverse clinical effects of late stent thrombosis. In this study, we present an example of how nanomedicine can offer solutions for improving stent coating manufacturing, by producing nanomaterials with tailored and controllable properties. The study is based on the exploitation of human platelets response towards carbon-based nanocoatings via atomic force microscope (AFM). AFM can facilitate the comprehensive analysis of platelets behavior onto stent nanocoatings and enable the study of thrombogenicity. Platelet-rich plasma from healthy donors was used for the real-time study of biointerfacial interactions. The carbon nanomaterials were developed by rf magnetron sputtering technique under controllable deposition conditions to provide favorable surface nanotopography. It was shown that by altering the surface topography of nanocoatings, the activation of platelets can be affected, while the carbon nanocoatings having higher surface roughness were found to be less thrombogenic in terms of platelets adhesion. This is an actual solution for improving the stent coating fabrication.

Factors that affect mass transport from drug eluting stents into the artery wall

Coronary artery disease can be treated by implanting a stent into the blocked region of an artery, thus enabling blood perfusion to distal vessels. Minimally invasive procedures of this nature often result in damage to the arterial tissue culminating in the re-blocking of the vessel. In an effort to alleviate this phenomenon, known as restenosis, drug eluting stents were developed. They are similar in composition to a bare metal stent but encompass a coating with therapeutic agents designed to reduce the overly aggressive healing response that contributes to restenosis. There are many variables that can influence the effectiveness of these therapeutic drugs being transported from the stent coating to and within the artery wall, many of which have been analysed and documented by researchers. However, the physical deformation of the artery substructure due to stent expansion, and its influence on a drugs ability to diffuse evenly within the artery wall have been lacking in published work to date. The paper highlights previous approaches adopted by researchers and proposes the addition of porous artery wall deformation to increase model accuracy.

Mechanisms of nonfatal acute myocardial infarction late after stent implantation: the relative impact of disease progression, stent restenosis, and stent thrombosis

BACKGROUND

The impact of stent restenosis, stent thrombosis, or progression of disease at another site as responsible mechanisms of acute myocardial infarction (AMI) after stent implantation is not clear.

METHODS

By searching our catheterization laboratory database for a 4-year period, 91 cases of nonfatal AMI at least 1 month after stent implantation (32.6% drug-eluting stents) were identified. By detailed comparison of post-AMI with the initial percutaneous coronary intervention angiogram, the mechanism of AMI was analyzed.

RESULTS

Acute myocardial infarction was attributed to disease progression at another site in 42 (46.2%), stent restenosis in 35 (38.4%), and stent thrombosis in 10 (11%) cases. The AMI mechanism could be either stent related or disease progression (nonidentifiable culprit lesion) in 4 cases (4.4%). The median time from percutaneous coronary intervention to AMI was 27, 19, and 9 months for disease progression at another site, restenosis, and stent thrombosis group, respectively (P = .03). ST-elevation myocardial infarction occurred in 38.1% of the disease progression, in 20% of the restenosis, and in 60% of the stent thrombosis cases (P = .046).

CONCLUSIONS

In a "real world" population, late after stent implantation, a patient has an almost equal probability to have suffered a nonfatal AMI from either stent restenosis/thrombosis or disease progression at another site. Continuous research efforts are necessary to equally address both stent therapy and disease progression.

Different sensitivity of human endothelial cells, smooth muscle cells and fibroblasts to topography in the nano-micro range

Cell adhesion, orientation and migration are influenced by surface topographies in the micrometer and nanometer range. In this work, we demonstrate the stimulation by topographical signals of human fibroblast cells (FCs), endothelial cells (ECs) and smooth muscle cells (SMCs). We systematically quantified the contact guidance alignment and directed migration of FCs, ECs and SMCs adhering to grooved substrates with lateral dimensions of 2-10microm and depths of 50-200nm. We found a common quantitative response characteristic of all three cell types: contact guidance significantly increased when the cells were cultured on substrates with smaller lateral dimensions or deeper grooves. Despite their general behavior, the three cell types exhibited a cell-type specific sensitivity to the groove patterns. The minimum groove depth to induce an orientation response and change cell shape was 50nm for FCs and about two times deeper for ECs and SMCs. The degree of alignment and directed migration of the FCs along the grooves was significantly stronger than for the ECs and SMCs. We demonstrate that ECs and SMCs can be stimulated by topographical signals but are less sensitive than FCs.

Estrogen-eluting stents

Coronary stenting is routinely utilized to treat symptomatic obstructive coronary artery disease. However, the efficacy of bare metal coronary stents has been historically limited by restenosis, which is primarily due to excessive neointima formation. Drug-eluting stents (DES) are composed of a stainless steel backbone encompassed by a polymer in which a variety of drugs that inhibit smooth muscle cell proliferation and excessive neointima formation are incorporated. DES have significantly reduced the incidence of restenosis but are also associated with a small (~0.5% per year) but significant risk of late stent thrombosis. In that regard, estrogen-eluting stents have also undergone clinical evaluation in reducing restenosis with the additional potential benefit of enhancing reendothelialization of the stent surface to reduce stent thrombosis. Estrogen directly promotes vasodilatation, enhances endothelial healing, and prevents smooth muscle cell migration and proliferation. Due to these mechanisms, estrogen has been postulated to reduce neointimal hyperplasia without delaying endothelial healing. In animal studies, estrogen treatment was effective in decreasing neointimal hyperplasia after both balloon angioplasty and stenting regardless of the method of drug delivery. The first uncontrolled human study using estrogen-coated stents demonstrated acceptable efficacy in reducing late lumen loss. However, subsequent randomized clinical trials did not show superiority of estrogen-eluting stents over bare metal stents or DES. Further studies are required to determine optimal dose and method of estrogen delivery with coronary stenting and whether this approach will be a viable alternative to the current DES armamentarium.

Combination of C-reactive protein and cardiac troponin I for predicting adverse cardiac events after sirolimus-eluting stent implantation

AIMS

We assessed the predictive value of a combination of C-reactive protein (CRP) and cardiac troponin I (cTnI) in a 2-year prospective study in patients undergoing sirolimus-eluting stents (SES) implantation.

METHODS AND RESULTS

CRP and cTnI levels were examined 1 day before and after SES implantation in 322 patients. CRP level greater than 3.0 mg/l (defining the high serum CRP levels) and cTnI level greater than 1.0 microg/l (defining the high serum cTnI levels) were considered abnormal. Major adverse cardiac events were defined as nonfatal myocardial infarction (MI), target vessel revascularization (TVR), and cardiac death. After 2+/-0.2 years of follow-up, there were 11 MI, 19 TVR, and 11 cardiac deaths. After adjustment for relevant risk factors, the combination of high CRP and cTnI remained predictive of adverse cardiac events, with the presence of both elevated CRP and cTnI associated with the highest risks of MI [relative risk (RR): 4.0, 95% confidence interval (CI): 2.3-6.4], TVR (RR: 3.3, 95% CI: 2.8-5.3), and cardiac death (RR: 4.2, 95% CI: 2.6-6.0). The presence of either a high CRP or cTnI was associated with an intermediated risk of MI (RR: 1.7, 95% CI: 1.2-2.2), TVR (RR: 1.5, 95% CI: 1.2-2.7), and cardiac death (RR: 2.8, 95% CI: 2.2-3.6).

CONCLUSION

The combination of elevated CRP and cTnI increased the risk of adverse cardiac events, demonstrating the additive impacts of active inflammation and myocardial injury on prognosis after SES implantation.

Comparison of drug-eluting stents and coronary artery bypass surgery for the treatment of multivessel coronary disease: three-year follow-up results from a single institution

BACKGROUND

Numerous studies have compared the outcomes of coronary artery bypass grafting (CABG) surgery and coronary stenting for the treatment of multivessel coronary disease. In 2003, drug-eluting stents were introduced with the hope of reducing restenosis. However, limited information exists on the comparison of drug-eluting stents and CABG surgery. The long-term outcome of drug-eluting stents compared with that of CABG surgery is also unclear.

METHODS AND RESULTS

We identified 3720 consecutive patients with multivessel disease who underwent isolated CABG surgery or received drug-eluting stents between April 1, 2004, and December 31, 2005, and we compared safety (total mortality, myocardial infarction, and stroke) and efficacy (target-vessel revascularization) during a 3-year follow-up. These outcomes were compared after adjustment for differences in baseline risk factors. Patients who underwent CABG (n=1886) were older and had more comorbidities than patients who received drug-eluting stents (n=1834). Patients receiving drug-eluting stents had considerably higher 3-year rates of target-vessel revascularization. Drug-eluting stents were also associated with higher rates of death (adjusted hazard ratio, 1.62; 95% confidence interval, 1.07 to 2.47) and myocardial infarction (adjusted hazard ratio, 1.65; 95% confidence interval, 1.15 to 2.44). The risk adjusted rate of stroke was similar in the 2 groups (hazard ratio, 0.92; 95% confidence interval, 0.69 to 1.51).

CONCLUSIONS

In a cohort of patients with multivessel disease, CABG was associated with lower rates of death, myocardial infarction, and target-vessel revascularization than drug-eluting stents.

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

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Coronary stent assessment with 64-slice multislice computed tomography: a literature review

Coronary in-stent restenosis (ISR) and thrombosis cause recurrent cardiac ischemia, require repeat investigations, and have significant clinical and financial implications. As coronary stenting becomes widespread, the number of patients with recurrent ischemia is increasing. ISR and thrombosis occur in up to 10 and 0.8%, respectively, of patients with drug-eluting stents. A noninvasive investigation for symptomatic stented patients is required to identify stent thrombosis, ISR, and de novo lesions in native coronary arteries. The difficulties in using computed tomography to image high-density materials adjacent to moving calcified vessels have been reduced with advances in spatial and temporal resolution and reconstruction software. This review examines the advantages and disadvantages of 64-slice multislice computed tomography for coronary stent evaluation, explaining the diagnostic difficulties and outlining techniques to optimize diagnostic accuracy.

Coronary artery stents: Part I. Evolution of percutaneous coronary intervention

The subspecialty of interventional cardiology has made significant progress in the management of coronary artery disease over the past three decades with the development of percutaneous coronary transluminal angioplasty, atherectomy, and bare-metal and drug-eluting stents (DES). Bare-metal stents (BMS) maintain vessel lumen diameter by acting as a scaffold and prevent collapse incurred by angioplasty. However, these devices cause neointimal hyperplasia leading to in-stent restenosis and requiring reintervention in more than 20% of patients by 6 mo. DES (sirolimus and paclitaxel) prevent restenosis by inhibiting neointimal hyperplasia. However, DESs also delay endothelialization, causing the stents to remain thrombogenic for an extended, yet unknown, period of time. Late stent thrombosis is associated with a 45% mortality rate. Premature discontinuation of antiplatelet therapy, particularly clopidogrel, is the strongest predictor of stent thrombosis. Sixty percent of patients receive stents for off-label (unapproved) indications, which also increases the frequency of stent thrombosis. Clopidogrel and aspirin are the cornerstone of therapy in the prevention of stent thrombosis in both BMS and DES. Recommendations pertaining to the optimal duration of dual-antiplatelet therapy have been debated. Both the Food and Drug Administration and the American Heart Association/American College of Cardiologists, in association with other major societies, have made recommendations to extend the duration of dual-antiplatelet therapy in patients with DES to 1 yr. The 6-wk duration of dual-antiplatelet therapy in patients with BMS remains unchanged. All patients with coronary stents must remain on life-long aspirin monotherapy. Since the introduction of percutaneous transluminal coronary angioplasty for the treatment of coronary atherosclerosis, the practice of percutaneous coronary intervention has undergone a dramatic transformation from simple balloon dilation catheters to sophisticated mechanical endoprostheses. These advancements have impacted the practice of perioperative medicine. In this series of two articles, in Part I we will review the evolution of percutaneous coronary intervention and discuss the issues associated with percutaneous transluminal coronary angioplasty and coronary stenting; in Part II we will discuss perioperative issues and management strategies of coronary stents during noncardiac surgery.

Outcomes following coronary stenting in the era of bare-metal vs the era of drug-eluting stents

CONTEXT

Although drug-eluting stents reduce restenosis rates relative to bare-metal stents, concerns have been raised that drug-eluting stents may also be associated with an increased risk of stent thrombosis. Our study focused on the effect of stent type on population-based interventional outcomes.

OBJECTIVE

To compare outcomes of Medicare beneficiaries who underwent nonemergent coronary stenting before and after the availability of drug-eluting stents.

DESIGN, SETTING, AND PATIENTS

Observational study of 38,917 Medicare patients who underwent nonemergent coronary stenting from October 2002 through March 2003 when only bare-metal stents were available (bare-metal stent era cohort) and 28,086 similar patients who underwent coronary stenting from September through December 2003, when 61.5% of patients received a drug-eluting stent and 38.5% received a bare-metal stent (drug-eluting stent era cohort). Follow-up data were available through December 31, 2005.

MAIN OUTCOME MEASURES

Coronary revascularization (percutaneous coronary intervention, coronary artery bypass surgery), ST-elevation myocardial infarction, survival through 2 years of follow-up.

RESULTS

Relative to the bare-metal stent era, patients treated in the drug-eluting stent era had lower 2-year risks for repeat percutaneous coronary interventions (17.1% vs 20.0%, P < .001) and coronary artery bypass surgery (2.7% vs 4.2%, P < .01). The difference in need for repeat revascularization procedures between these 2 eras remained significant after risk adjustment (hazard ratio, 0.82; 95% confidence interval, 0.79-0.85). There was no difference in unadjusted mortality risks at 2 years (8.4% vs 8.4%, P =.98 ), but a small decrease in ST-elevation myocardial infarction existed (2.4% vs 2.0%, P < .001). The adjusted hazard of death or ST-elevation myocardial infarction at 2 years was similar (hazard ratio, 0.96; 95% confidence interval, 0.92-1.01).

CONCLUSION

The widespread adoption of drug-eluting stents into routine practice was associated with a decline in the need for repeat revascularization procedures and had similar 2-year risks for death or ST-elevation myocardial infarction to bare-metal stents.