Second-Generation Drug-Eluting Stents and the Continuous Need for Rapidly Available Real-World Data

Stirred, shaken, or stagnant: What goes on at the blood-biomaterial interface

There is a widely recognized need to improve the performance of vascular implants and external medical devices that come into contact with blood by reducing adverse reactions they cause, such as thrombosis and inflammation. These reactions lead to major adverse cardiovascular events such as heart attacks and strokes. Currently, they are managed therapeutically. This need remains unmet by the biomaterials research community. Recognized stagnation of the blood-biomaterial interface research translates into waning interest from clinicians, funding agencies, and practitioners of adjacent fields. The purpose of this contribution is to stir things up. It follows the 2014 BloodSurf meeting (74th International IUVSTA Workshop on Blood-Biomaterial Interactions), offers reflections on the situation in the field, and a three-pronged strategy integrating different perspectives on the biological mechanisms underlying blood-biomaterial interactions. The success of this strategy depends on reengaging clinicians and on the renewed cooperation of the funding agencies to support long-term efforts.

Comparing clinical outcomes for a twelve-month trial of zotarolimus- and everolimus-eluting stents in patients with coronary artery disease: data from the THCRIC registry

OBJECTIVES

New-generation coronary stents including zotarolimus- and everolimus-eluting stents (ZES and EES) have been shown to decrease the risk of restenosis. The purpose of this study was to compare the safety and efficacy of ZES and EES over a 12-month clinical follow up, in routine clinical practice.

METHODS

This is an observational study in which 1029 consecutive patients treated with ZES (n = 669) or EES (n = 360) were enrolled. The study endpoint was major adverse cardiac events (MACE), defined as cardiac death, nonfatal myocardial infarction (MI), and target lesion or vessel revascularization at 12 months.

RESULTS

Follow up was completed among 94.9% of the patients. The overall MACE occurred in 4 (0.6%) and 7 (2.0%) patients in the ZES and EES group, respectively. The occurrence of other cardiac events including nonfatal MI and target vessel or lesion revascularization was 1 (0.2%) versus 1 (0.3%) and 7 (1.1%) versus 5 (1.4%), respectively, in the ZES and EES groups of patients. Despite a slightly lower rate of MACE and cardiac death in the ZES group, the difference between these two groups was not significant (n = 0.064 for overall MACE, p = 0.129 for cardiac mortality, n = 0.999 for nonfatal MI, n = 0.468 for target vessel and n = 0.999 for target lesion revascularization).

CONCLUSIONS

According to our results, it could be concluded that the difference in the rate of MACE between the ZES and EES groups was not statistically significant at 12-month follow up.

Clinical impact of routine follow-up coronary angiography after second- or third-generation drug-eluting stent insertion in clinically stable patients

BACKGROUND/AIMS

In the bare-metal stent era, routine follow-up coronary angiography (RFU CAG) was used to ensure stent patency. With the advent of drug-eluting stents (DESs) with better safety and efficacy profiles, RFU CAG has been performed less often. There are few data on the clinical impact of RFU CAG after second- or third-generation DES implantation in clinically stable patients with coronary artery disease; the aim of this study was to examine this issue.

METHODS

We analyzed clinical outcomes retrospectively of 259 patients who were event-free at 12-month after stent implantation and did not undergo RFU CAG (clinical follow-up group) and 364 patients who were event-free prior to RFU CAG (angiographic follow-up group). Baseline characteristics were compared between the groups.

RESULTS

The Kaplan-Meier estimated total survival and major adverse cardiac event (MACE)-free survival did not differ between the groups (p = 0.100 and p = 0.461, respectively). The cumulative MACE rate was also not different between the groups (hazard ratio, 0.85; 95% confidence interval, 0.35 to 2.02). In the angiographic follow-up group, 8.8% revascularization was seen at RFU CAG.

CONCLUSIONS

RFU CAG did not affect long-term clinical outcome after second- or third-generation DES implantation in clinically stable patients.

A Randomized Comparison between Everolimus-Eluting Stent and Cobalt Chromium Stent in Patients with Acute ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention Using Routine Intravenous Eptifibatide: The X-MAN (Xience vs. Multi-Link Stent in Acute Myocardial Infarction) Trial, A Pilot Study

The objective of this study is to determine the efficacy and safety of an everolimus-eluting stent (EES/Xience; Abbott Vascular, Santa Clara, CA) compared with a cobalt chromium stent (CoCr/Multi-Link Vision; Abbott Vascular) in patients with acute ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with routine administration of eptifibatide infusion. This is a prospective, single center, randomized trial comparing EES (n = 75) and CoCr stent (n = 75) implantation in patients with acute STEMI undergoing primary PCI. Intravenous eptifibatide administration was mandatory by protocol in this pilot study. The primary efficacy endpoint was major adverse cardiac events (MACE) at 30 days, defined as the composite of death, reinfarction, and target vessel revascularization. Secondary safety endpoints were stent thrombosis at 30 days and in-hospital bleeding event. Acute reperfusion parameters were also assessed. One-month MACE rate did not differ between EES and CoCr group (1.3 vs. 1.3%, p = 1.0). No stent thrombosis cases were observed in the EES group. The groups did not differ with respect to in-hospital bleeding events (5 vs. 9%, p = 0.37), achievement of final thrombolysis in myocardial infarction flow 2 or 3 (p = 0.21), achievement of myocardial blush grade 2 or 3 (p = 0.45), creatine kinase-MB level at 8 to 12 hours after stenting (p = 0.29), and left ventricular ejection fraction (p = 0.21). This pilot study demonstrates that after one-month follow-up, the use of EES is as safe and effective as the use of CoCr stents in patients with acute STEMI undergoing primary PCI with routine administration of intravenous eptifibatide.

Clinical outcomes after zotarolimus and everolimus drug eluting stent implantation in coronary artery bifurcation lesions: insights from the RESOLUTE All Comers Trial

OBJECTIVE

We investigated clinical outcomes after treatment of coronary bifurcation lesions with second generation drug eluting stents (DES).

DESIGN

Post hoc analysis of a randomised, multicentre, non-inferiority trial.

SETTING

Multicentre study.

PATIENTS

All comers study with minimal exclusion criteria.

INTERVENTIONS

Patients were treated with either zotarolimus or everolimus eluting stents. The patient population was divided according to treatment of bifurcation or non-bifurcation lesions and clinical outcomes were compared between groups.

MAIN OUTCOMES MEASURES

Clinical outcomes within 2-year follow-up.

RESULTS

A total of 2265 patients were included in the present analysis. Two-year follow-up data were available in 2223 patients: 1838 patients in the non-bifurcation group and 385 patients in the bifurcation group. At 2-year follow-up the bifurcation and the non-bifurcation lesion groups showed no significant differences in terms of cardiac death (2.3 vs 2.1, p=0.273), target lesion failure (9.7% vs 13.8%, p=0.255), major adverse cardiac events (11.5% vs 15.1%, p=0.305), target lesion revascularisation (4.7% vs 6.0%, p=0.569), and definite or probable stent thrombosis (1.6% vs 1.8%, p=0.419).

CONCLUSIONS

The use of second generation DES for the treatment of coronary bifurcation lesions was associated with similar long term mortality and clinical outcomes compared with non-bifurcation lesions.

[Cardiovascular diseases in the focus of health economics. The example of drug-eluting vascular stents in coronary heart disease]

Coronary heart disease is an important disorder in Western industrialized societies, with regard to both the epidemiologic and economic burden of illness. A modern therapeutic strategy consists of coronary interventions and the implantation of drug-eluting vascular stents. The cost-effectiveness of such drug-eluting stents has been an important subject of health-economic evaluation research in recent years. This article presents two examples of such studies and deals with the question whether existing study projects are able to provide sufficient evidence for allocation decisions in health care. On this basis we discuss important challenges for future health economic analysis. A key conclusion is the need for long-term and cross-sectoral evaluation strategies that could be based on routinely collected health care data. Supplemented by health economic results from clinical trials, the use of such data would lead to a broader data basis for allocation decisions in health care.

Comparison of optical coherence tomographic assessment between first- and second-generation drug-eluting stents

PURPOSE

There is a lack of sufficient data in comparison of optical coherence tomographic (OCT) findings between first- and second-generation drug-eluting stents (DES). Compared to first-generation (i.e., sirolimus- or paclitaxel-eluting stents), second-generation DESs (i.e., everolimus- or biolinx-based zotarolimus-eluting stents) might have more favorable neointimal coverage.

MATERIALS AND METHODS

Follow-up OCT findings of 103 patients (119 lesions) treated with second- generation DESs were compared with those of 139 patients (149 lesions) treated with first-generation DESs. The percentage of uncovered or malapposed struts, calculated as the ratio of uncovered or malapposed struts to total struts in all OCT cross-sections, respectively, was compared between the two groups.

RESULTS

Both DES groups showed similar suppression of neointimal hyperplasia (NIH) on OCT (mean NIH cross-sectional area; second- vs. first-generation=1.1±0.5 versus 1.2±1.0 mm², respectively, p=0.547). However, the percentage of uncovered struts of second-generation DESs was significantly smaller than that of first-generation DESs (3.8±4.8% vs.7.5±11.1%, respectively, p<0.001). The percentage of malapposed struts was also significantly smaller in second-generation DESs than in first-generation DESs (0.4±1.6% vs.1.4±3.7%, respectively, p=0.005). In addition, intra- stent thrombi were less frequently detected in second-generations DESs than in first-generation DESs (8% vs. 20%, respectively, p=0.004).

CONCLUSION

This follow-up OCT study showed that second-generation DESs characteristically had greater neointimal coverage than first-generation DESs.

TWENTE Study: The Real-World Endeavor Resolute Versus Xience V Drug-Eluting Stent Study in Twente: study design, rationale and objectives

Background. New-generation drug-eluting stents (DES) may solve several problems encountered with first-generation DES, but there is a lack of prospective head-to-head comparisons between new-generation DES. In addition, the outcome of regulatory trials may not perfectly reflect the outcome in 'real world' patients.Objectives. To compare the efficacy and safety of two new-generation DES in a 'real world' patient population.Methods. A prospective, randomised, single-blinded clinical trial to evaluate clinical outcome after Endeavor Resolute vs. Xience V stent implantation. The primary endpoint is target vessel failure at one-year follow-up. In addition, the study comprises a two-year and an open-label five-year follow-up. (Neth Heart J 2010;18:360-4.).