Drug-Eluting Stents and SYNTAX Score

Study Questions:

How does the complexity of coronary artery disease (CAD) impact the relative efficacy of early- versus new-generation drug-eluting stents (DES)?


The authors performed a pooled analysis of four randomized controlled trials comparing early- versus new-generation DES. The primary clinical endpoint was the composite of cardiac death, myocardial infarction, or ischemia-driven target lesion revascularization (TLR). The principal effectiveness and safety endpoints were TLR and definite stent thrombosis (ST), respectively. Outcomes were compared between the new- and early-generation DES among patients with lower complexity (SYNTAX [Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery] score ≤11) and higher complexity (SYNTAX score >11).


A total of 6,081 patients were included in the study, of whom new-generation DES were used in 4,554 patients. Compared with earlier stents, new-generation DES reduced the primary endpoint (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.63-0.89; p = 0.001) across all patients, and there was no interaction between the SYNTAX score for this endpoint. The efficacy of these stents was greater for TLR and ST among the patients with more complex disease. In patients with SYNTAX score >11, new-generation DES reduced TLR (HR, 0.36; p interaction = 0.059) and definite ST (HR, 0.28; p interaction = 0.013) to a greater extent than in the low-complexity group. A lower mortality was noted with new-generation DES among patients with SYNTAX score >11 (HR, 0.45; p =0.003), but not in patients with SYNTAX score <11 (p interaction = 0.042).


The relative safety and efficacy of new-generation DES is enhanced among patients with more complex CAD.


The new-generation DES have demonstrated excellent clinical outcomes with low rates of TLR and ST compared with earlier DES or bare-metal stents (mostly indirect analysis). This study suggests that the relative efficacy of these stents is greater in patients with more complex disease, although the new-generation DES were still better among those with less complex anatomy. This study validates the nearly universal use of new-generation DES for patients undergoing contemporary percutaneous coronary intervention.

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