Contemporary Stents Focus of Review in Zipes Lecture
In the four decades since percutaneous coronary intervention (PCI) was introduced, coronary stents have become integral to the management of patients with coronary artery disease requiring revascularization in the majority of patients. Reduction of coronary risk factors and aggressive medical therapy remain cornerstones of treatment for these patients.
Advances in PCI techniques and stent technology over the last three decades have reduced periprocedural complications and improved patient outcomes with this revascularization strategy. Procedural success rates are in the 93 to 99 percent range, adverse event rates are 4.53 percent, and the mortality rate for elective procedures is 0.2 percent, according to data from ACC’s CathPCI Registry from January 2010 to June 2011. In 2010, an estimated 954,000 patients underwent PCI in the U.S.
The development of drug-eluting stents (DES) has been a major contributor to the improved outcomes, by addressing the in-stent restenosis seen with bare-metal stents, which has been a substantial complication after PCI.
The role of more contemporary DES, including those with bioresorbable polymers and permanent polymers, and their impact on patient outcomes will be discussed by Sripal Bangalore, MBBS, MHA, FACC, of New York University Langone Medical Center, in this year’s Douglas P. Zipes, MD, MACC, Distinguished Young Scientist Lecture.
In his lecture, Bangalore will review outcomes with the bioresorbable polymers, durable polymer stents, and the older-generation DES and bare-metal stents. Bangalore will try to answer the question of whether the latest generation of DES reduce death or myocardial infarction (MI) compared with older generation stents. Prior randomized trials of PCI versus medical therapy in patients with stable coronary artery disease have failed to show a reduction in death or MI with PCI. Similarly, trials of PCI versus coronary artery bypass graft (CABG) surgery have shown superiority of CABG for hard outcomes. However, both of these sets of trials compared PCI using older generation stents. Whether newer generation stents have superior outcomes will dictate whether the results from the trials with older stents are still relevant and how they contribute to current clinical decision making.
Bangalore is the principal investigator of the National Heart, Lung, and Blood Institute-sponsored ISCHEMIA-CKD trial, and along with its parent ISCHEMIA trial, it is amongst the trials that are eagerly awaited to provide evidence comparing optimal medical therapy alone with that of revascularization in patients with stable ischemic heart disease. The trials will compare the best of contemporary medical therapy alone versus the addition of optimal revascularization therapy using the current generation of stents.
“Even though we have newer generation stents, with what appears to be improvements in their coatings and design, we must thoroughly understand the data to determine the best treatment strategy for each patient, whether that is medical therapy, surgery, or PCI,” says Bangalore. “Along with the other presentations in this session, I hope my lecture provides a basis for these clinical decisions.”
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