Coronary Artery Disease Progression Late After Successful Stent Implantation

Study Questions:

What is the importance of 5-year coronary artery disease (CAD) progression after successful stenting?

Methods:

This study followed for 5 years, 428 consecutive patients randomized to drug-eluting versus bare-metal stents, with successful stenting documented by freedom from symptoms/events and no ischemic perfusion defects (PDs) after 6 months. Rest/stress scintigraphic scans were repeated after 60 months. Late events and new PDs in areas remote from stented vessels indicated CAD progression. Categorical variables were compared using the Fisher exact test or the McNemar test and the Student t test for continuous variables as appropriate.

Results:

During follow-up, 110 of 428 (25.7%) patients had 150 clinical events: 43 patients (10%) died, 36 (8.4%) suffered a myocardial infarction, and 71 (16.6%) needed repeat revascularization. Event rates were lower in remote versus target-vessel areas (9.8% vs. 14.3%, p = 0.019). Remote myocardial infarction and repeat revascularization accounted for 46 of 124 (37.1%) nonfatal events and were similar for both stent types. Five-year scintigraphic studies in patients without follow-up events showed 23.3% new PDs, 71% of which were asymptomatic. Remote defects accounted for 37.5% of PDs and were similar for both stent types.

Conclusions:

The authors concluded that even 5 years after stenting, target-vessel events and/or new PDs remained more frequent than CAD progression, assessed by remote events and/or new PDs.

Perspective:

This study suggests that in patients who are successfully and completely revascularized, one in four will have an event at 5 years, and this event will be due to disease progression in 40-50%. In those who have not had an event, one in four will have clinically significant inducible ischemia, and again, this will be from disease progression in 40-50%. These findings highlight the importance of aggressive evidence-based secondary prevention and lifestyle modification in all patients with CAD. The fact that the majority of late events and new perfusion defects are target-vessel–related may prompt clinicians to consider bypass surgery for proximal diffuse disease of the left anterior descending artery.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Myocardial Infarction, Follow-Up Studies, Secondary Prevention, Glaucoma, Open-Angle, Vascular Grafting, Coronary Vessels, Sirolimus, Angioplasty, Stents, Disease Progression


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