DES may soon be standard for certain patients
WASHINGTON — In the near future, drug-eluting stents may be the default therapy for various patients, including those with STEMI and left main disease, speakers said at Cardiovascular Research Technologies 2012.
Although physicians and researchers have valid concerns, there is considerable evidence suggesting that drug-eluting stents (DES) should be default therapy for STEMI patients, Gregg W. Stone, MD, director of CV research and education and professor of medicine, division of cardiology, Columbia University Medical Center/New York-Presbyterian Hospital, said during a presentation.
In terms of efficacy, several studies associate DES with reductions in target lesion revascularization and restenosis, as compared with bare metal stents (BMS). In HORIZONS-AMI, for example, researchers found a decrease in angiographic restenosis of 23% in the paclitaxel-eluting stent (Taxus, Boston Scientific) group vs. 10% in the BMS (Express, Boston Scientific) group at 13 months.
Even more importantly, Stone said, DES are safe for use in STEMI patients. In HORIZONS-AMI, researchers reported no significant differences in major adverse CV events, stent thrombosis or mortality at 3 years. Further, these results are consistent with those of eight randomized trials involving 6,026 patients, approximately half of whom participated in HORIZONS-AMI, with 5-year follow-up. Additionally, Stone said these trials evaluated first-generation DES. Studies examining newer stents, such as EXAMINATION, which compared an identical BMS (Multi-Link Vision, Abbott) with a fluoropolymer-coated everolimus-eluting stent (XIENCE V, Abbott), suggest that DES may be even more beneficial for patients with STEMI than BMS.
Physicians who still harbor concerns could prescribe more potent P2Y12 inhibitors such as prasugrel (Effient, Eli Lilly) and ticagrelor (Brilinta, AstraZeneca) to decrease the chances of stent thrombosis, Stone said. For those concerned about adherence to dual antiplatelet therapy (DAPT) in STEMI, he cited the GHOST study, recently presented by Maurizio Menichelli, MD, of Umberto Hospital in Italy, at TCT 2011. The study showed that it is possible to obtain an accurate medical history in the ED from STEMI patients undergoing primary percutaneous coronary intervention, despite certain issues, such as a lack of medical records or access to family members. By doing so, the physician can determine whether the patient can adhere to DAPT.
“DES should be the default therapy for patients undergoing primary PCI for STEMI, even today, unless the patient requires surgery necessitating DAPT discontinuation within 6 to 12 months; the patient is actively bleeding or has had a recent major bleed; or DAPT compliance is likely to be poor in the first 6 to 12 months based on your ED interview,” Stone said.
Left main disease
Adnan Kastrati, MD, professor of interventional cardiology at Technische Universitat, Munich, Germany, highlighted the potential for DES to become the default therapy for patients with left main disease as well. Data from observational studies and one small randomized trial, for instance, indicate that patients had improved survival, free of major adverse CV events with DES vs. BMS.
DES also appears to be as safe as CABG in patients with left main disease, according to Kastrati. A subset analysis of 705 patients who were randomly assigned to CABG or PCI with DES in the SYNTAX trial revealed no significant differences in major CV events or MI. Moreover, although CABG was associated with less target vessel revascularization, it was also associated with more cerebrovascular accidents. Four-year follow-up data from this trial also did not show any differences between the DES and CABG groups regarding mortality and MI; yet, the risk for cerebrovascular accidents continued to be significantly lower with DES whereas the risk for target vessel revascularization was lower with CABG. Several other studies have yielded similar results, Kastrati said.
“Based on these data, I can say that the available evidence supports the use of DES in patients with left main disease,” he said. – by Melissa Foster
For more information:
- Kastrati A. My projections: DES will be the default therapy for unprotected LM.
- Stone GW. My projections: DES will be the default therapy for STEMI. Both presented at: the Cardiovascular Research Technologies 2012; Feb. 4-7, 2012; Washington.
Disclosure: Dr. Kastrati reports no relevant financial disclosures. Dr. Stone is a consultant for Abbott Vascular, Boston Scientific and Medtronic.
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