Clinical Outcomes With Drug-Eluting and Bare Metal Stents in Patients With ST-Segment Elevation Myocardial Infarction: Evidence From a Comprehensive Network Meta-Analysis

Study Questions:

What is the relative safety and efficacy of different drug-eluting stents (DES) and bare-metal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI)?

Methods:

Randomized controlled trials comparing currently US approved DES or DES with BMS in patients with STEMI were searched through MEDLINE, EMBASE, and Cochrane databases. Information on study design, inclusion and exclusion criteria, sample characteristics, and clinical outcomes was extracted. Dichotomous outcome variables at specific time points were compared with odds ratios (ORs) with 95% confidence intervals (CIs) by means of network meta-analysis with a random-effect model.

Results:

Twenty-two trials including 12,453 randomized patients were analyzed. At 1-year follow-up, cobalt-chromium everolimus-eluting stents (CoCr-EES) were associated with significantly lower rates of cardiac death or MI and stent thrombosis (ST) than BMS. The difference in ST was apparent as early as 30 days and was maintained for 2 years. CoCr-EES were also associated with significantly lower rates of 1-year ST than paclitaxel-eluting stents (PES). Sirolimus-eluting stents (SES) were also associated with significantly lower rates of 1-year cardiac death/MI than BMS. CoCr-EES, PES, and SES, but not zotarolimus-eluting stents had significantly lower rates of 1-year target vessel revascularization (TVR) than BMS, with SES also showing lower rates of TVR than PES.

Conclusions:

The authors concluded that in patients with STEMI, steady improvements in outcomes have been realized with the evolution from BMS to first-generation and now second-generation DES.

Perspective:

The most important finding of this study appears to be the significantly lower risk of 1-year cardiac death/MI, MI, and ST with CoCr-EES compared to BMS, a finding not previously reported for any DES in the setting of STEMI. Overall, in patients with STEMI, steady improvements in outcomes are apparent with the evolution from BMS to first-generation and now second-generation DES, with the most favorable safety and efficacy profile demonstrated with CoCr-EES. Additional trials in patients with stable coronary artery disease and acute coronary syndrome are required to determine the relative safety and efficacy of other second-generation DES with durable polymers, or with bioabsorbable polymers compared to CoCr-EES, which based on the present data, can be considered the gold standard for comparison.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Paclitaxel, Coronary Artery Disease, Myocardial Infarction, Acute Coronary Syndrome, Cobalt, Thrombosis, Drug-Eluting Stents, Chromium, Sirolimus, Stents


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