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DES superior to BMS in patients with 1 month of DAPT
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In a meta-analysis of three trials of patients who received 1 month of dual antiplatelet therapy after PCI, drug-eluting stents were superior to bare-metal stents in MACE, target lesion revascularization, target vessel revascularization and MI.
The researchers analyzed three randomized trials including 3,943 patients (mean age, 76-81 years; 62% men) who received a DES or BMS and had only 1 month of DAPT, usually clopidogrel plus aspirin.
Outcomes of interest included MACE, whose definition varied by trial; MI; TVR; ischemia-driven TLR; cardiac mortality; all-cause mortality; stent thrombosis; and bleeding complications, all at 1 year.
Compared with BMS, DES was associated with reduction in 1-year risk for MACE (OR = 0.68; 95% CI, 0.57-0.82), TLR (OR = 0.38; 95% CI, 0.22-0.67), TVR (OR = 0.5; 95% CI, 0.38-0.65) and MI (OR = 0.51; 95% CI, 0.31-0.83), Rahman Shah, MD, from the division of cardiovascular medicine at the University of Tennessee Health Science Center, and colleagues wrote.
DES conferred lower rates of stent thrombosis (1.8% vs. 2.8%). This was not significant in a random-effects model (OR = 0.566; 95% CI, 0.273-1.175), but it was significant in a fixed-effects model (OR = 0.642; 95% CI, 0.416-0.991), the researchers wrote.
There was no difference between the groups in all-cause mortality (OR = 0.876; 95% CI, 0.709-1.081), cardiac mortality (OR = 0.842; 95% CI, 0.636-1.115) or BARC bleeding (OR = 0.849; 95% CI, 0.662-1.088), Shah and colleagues found.
No role for BMS
In a related editorial, Cardiology Today’s Intervention Editorial Board Member Dean J. Kereiakes, MD, FACC, FSCAI, medical director of The Christ Hospital Heart and Vascular Center in Cincinnati, medical director of the Carl and Edyth Lindner Center for Research and Education at The Christ Hospital and professor of clinical medicine at Ohio State University, wrote that the study and related data “consistently demonstrate significantly lower rates of adverse clinical events (ie, MACE and [stent thrombosis]) in patients treated with DESs regardless of DAPT duration or the time course of DAPT discontinuation after stenting. The pathophysiologic mechanism(s) for DES benefit include (1) thinner struts in contemporary DESs, (2) thromboresistant polymer, and (3) suppression of stent-mediated endoluminal injury and inflammation by anti-inflammatory and antiproliferative medications (eluted by DESs, not BMSs). Further, the myths of BMS being more suitable for patients with larger vessels and shorter lesions has been objectively dispelled by multiple studies.”
“There is no role for BMS in conjunction with short-duration DAPT in patients at [high bleeding risk],” Kereiakes concluded. “What role, if any, remains for BMS in the context of current DES technology remains to be determined.”
Except in rare cases
In an Editor’s Note, Cardiology Today’s Intervention Editorial Board Member Ajay J. Kirtane, MD, SM, wrote that the evidence is strong that DES is superior to BMS, but the present study should be interpreted with caution because two of the stents studied are not available in the United States, and “there are still very rarely occurring clinical scenarios (eg, active severe bleeding, need for expedited surgical procedures, or incontrovertible evidence of an inability to take medications for a month) that may require DAPT durations even shorter than 1 month. Whether percutaneous coronary intervention is indicated at all in these scenarios is always a legitimate question, but for the very short term (until newer DES data and/or device approvals emerge), I personally would grant a respite to the extremely rare case of BMS implantation that might occur in these extreme scenarios.” – by Erik Swain
References:
Kereiakes DJ. JAMA Cardiol. 2018;doi:10.1001/jamacardio.2018.3573.
Kirtane AJ. JAMA Cardiol. 2018;doi:10.1001/jamacardio.2018.3660.
Shah R, et al. JAMA Cardiol. 2018;doi:10.1001/jamacardio.2018.3551.
Disclosures: One author reports he receives grants and personal fees from Medtronic. Kereiakes reports he holds equity in Ablative Solutions and received personal fees for consulting from Abbott Vascular, Boston Scientific, Caliber Therapeutics/Orchestra BioMed, Micell Technologies, Sino Medical Sciences Technologies and Svelte Medical Systems. Kirtane reports he received institutional research grants from Abbott Vascular, Abiomed, Boston Scientific, Cardiovascular Systems Inc., CathWorks, Medtronic, Philips, Recor and Siemens.