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Higher late reinfarction rate seen with drug-eluting stents in primary PCI

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – In the setting of primary percutaneous coronary intervention for ST segment-elevated MI, use of drug-eluting stents (DES) rather bare metal stents (BMS) is associated with reduced long-term need for target vessel revascularization without significant differences in mortality, according to the results of a new meta-analysis.

“However, DES implantation was associated with an increased risk of very late stent thrombosis and reinfarction,” the researchers note in their report in the April 23rd issue of the Archives of Internal Medicine.

Dr. Giuseppe De Luca, with the Eastern Piedmont University in Novara, Italy, and colleagues explain that early meta-analyses of randomized trials indicated that DES implantation in STEMI patients was safe and effective but concerns have emerged about late stent thrombosis.

To look at long-term outcomes, the team performed a meta-analysis of patient-level data from 11 trials comparing BMS with either paclitaxel- or sirolimus-eluting stent implantation in 6298 STEMI patients; 3980 were assigned to DES and 2318 to BMS implantation.

At a mean follow-up of 3.3 years, the rate of target vessel revascularization was 12.7% in the DES group compared with 20.1% in the BMS group (hazard ratio 0.57; p<0.001), the authors report.

Respective mortality rates were 8.5% vs 10.2% (HR 0.85; p=0.11), reinfarction occurred in 9.4% versus 5.9% respectively (HR 1.12; p=0.36), and stent thrombosis was observed in 5.8% versus 4.3% (HR 1.13; p=0.38), the report indicates.

However, the investigators found that after 2 years, the risk of reinfarction was significantly higher for the DES group compared to the BMS group (6.6% vs 3.0%: HR 2.06; p=0.03), as was the rate of stent thrombosis (3.1% vs 1.4%: HR 2.81; p=0.04).

Even so, Dr. De Luca and colleagues point out, “There were no significant differences in overall or very late mortality, with the point estimate favoring DES in all periods.”

Still, the author of an invited critique writes, “Despite these worrisome findings, the authors conclude that this study provides reassurance that the DES benefits in STEMI warrant the potential risks.”

Dr. James M. Brophy, at McGill University Health Centre in Montreal, Quebec, Canada, discusses the interpretation of the findings, points out the “absolute necessity” of long-term patient compliance with dual antiplatelet therapy with drug-eluting stents, and notes their higher cost.

“Depending on repeat revascularizations costs,” he concludes, “DES instead of BMS after STEMI may be seen as a pricey dessert whose exact caloric and nutritional value remains uncertain.”

SOURCE:

Arch Intern Med 2012;172:611-621.