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Meta-analysis: DES reduced long-term target vessel revascularization

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Drug-eluting stents are associated with significant reductions in target vessel revascularization at long-term follow-up as compared with bare metal stents implanted in patients with STEMI undergoing primary percutaneous coronary intervention, according to results of a meta-analysis.

Researchers for the Drug-Eluting Stent in Primary Angioplasty (DESERT) Cooperation analyzed pooled, patient-level data from 11 trials with more than 6,200 randomized patients. At long-term follow-up (mean, 1,201 days), target vessel revascularization was significantly reduced in patients with a DES vs. BMS (12.7% vs. 20.1%; HR=0.57; 95% CI, 0.5-0.66). There were no significant differences in mortality (HR=0.85; 95% CI, 0.7-1.04), reinfarction (HR=1.12; 95% CI, 0.88-1.41) or stent thrombosis (HR=1.13; 95% CI, 0.86-1.47) observed with DES at long-term follow-up. However, the risk for very late stent thrombosis (3.1% vs. 1.4%; HR=1.89; 95% CI, 1.13-3.15) and very late reinfarction (6.6% vs. 3%; HR=1.57; 95% CI, 1.08-2.27) were increased with DES vs. BMS.

“Despite a slightly higher rate of very late reinfarction and stent thrombosis with [sirolimus-eluting stents] and [paclitaxel-eluting stents] compared with BMS, there were no significant differences in overall or very late mortality, with the point estimate favoring DES in all periods,” researchers wrote in the study.

The meta-analysis included completed, randomized controlled trials of DES vs. BMS in patients with STEMI. Data were extracted on 6,298 patients; 63.2% were randomly assigned to DES and 36.8% to BMS. Eleven trials met the inclusion criteria of randomized treatment allocation, follow-up data of more than 1 year and availability of complete clinical data.

In an accompanying editorial, James M. Brophy, MEng, MD, PhD, of McGill University Health Centre, Montreal, and Royal Victoria Hospital, Quebec, said the clinical question of whether patients with STEMI should receive DES still remains.

“As practitioners treat individual patients, the lack of information in this study about specific patient groups — diabetic patients and those with long coronary lesions or with smaller vessel disease — or specific stent models inhibits clinical decision making.

“Clinicians in favor of DES will perhaps argue that the current landmark analysis should, at most, be viewed as exploratory owing to its post-hoc nature (no individual trial prespecified a conditional analysis after 1 year of survival). However, others may cogently postulate that this evidence, in conjunction with previous nonexperimental data observing the same phenomena, provides a compelling safety argument to avoid using DES,” Brophy wrote.

For more information:

De Luca G. Arch Intern Med. 2012;172:611-621.

Brophy JM. Arch Intern Med. 2012;172:621-622.

Disclosure: The researchers report received assistance from: Abbott Vascular, Boston Scientific and Medtronic. Dr. Brophy reports no relevant financial disclosures.