Summary
The lead articles from the New England Journal of Medicine 9/14/06 reviewed new data showing benefits when comparing sirolimus-eluting stents to uncoated stents and when comparing paclitaxil eluting stents to uncoated stents.
There was a significant reduction in target-vessel revascularization at one year with the sirolimus-eluting stents compared to uncoated stents.
There was a trend (not statistically significant) toward reduction of serious adverse cardiac events at one year with paclitaxil-eluting stents compared to uncoated stents.
Analysis
Due to their lower rate of restenosis, drug-eluting stents (DES) are considered an advancement on the bare metal stents used in coronary artery interventions. DESs are widely used in the treatment of coronary artery disease.
The clear preference in our cath lab has been to use DES whenever possible. One exception might be if the vessel requiring intervention is a large caliber vessel with a straight-forward/easily stented lesion. Such a lesion might be considered for an uncoated stent. Otherwise, when the risk of restenosis is higher, the DESs are used due to their decreased rate of in-stent restenosis. A higher risk of restenosis is assumed with multi-vessel disease, small vessel disease, recurrent intervention, diabetics, etc. The Cypher stent has been the favorite at our cath lab based on some early results favoring its use over Taxus stents.
There has been recent concern about late stent thrombosis with the use of drug-eluting stents when compared to uncoated/bare metal stents. My understanding is that the concern raised pertains to registry data which has not yet been published. This data reportedly shows concern over an increased risk of late thrombosis when using DES compared to uncoated stents. However, there remains the question of the applicability of such data. There is speculation because of a possible lack of uniformity of background medications used. It is not clear what percentage of patients in the registry were on aspirin and/or Plavix - two medications proven to reduce in-stent thrombosis. Such a limitation is profound and has not limited the use of DES in the cardiac catheterization laboratory at my affiliated hospital (NYUMedicalCenter).
Two recent trials (from the New England Journal of Medicine 9/14/06) showed benefits of using drug-eluting stents for primary angioplasty, which is performing coronary intervention in the setting of an acute myocardial infarction (MI). (I would be glad to provide further evaluation and explanation of the results of these trials, as needed). There was a significant reduction in target-vessel revascularization at one year with the sirolimus-eluting stents compared to uncoated stents. There was a trend (not statistically significant) toward reduction of serious adverse cardiac events at one year with paclitaxil-eluting stents compared to uncoated stents. It must be noted that the trials each compared one drug-eluting stent to an uncoated stent and not to each other. Direct comparisons of the stents based on such trials should not be performed. Nonetheless, given the results of these trials and a statistically significant benefit with Cypher stents versus uncoated stents, there has been no change in our cath lab's preference to use DES over uncoated stents and to use Cypher stents over Taxus stents. This includes the treatment of MIs.
