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Outcomes Following Coronary Stenting in the Era of Bare-Metal vs the Era of Drug-Eluting Stents
David J. Malenka, MD;
Aaron V. Kaplan, MD;
F. Lee Lucas, PhD;
Sandra M. Sharp, SM;
Jonathan S. Skinner, PhD
JAMA. 2008;299(24):2868-2876.
Context Although drug-eluting stents reduce restenosis rates relative to bare-metal stents, concerns have been raised that drug-eluting stents may also be associated with an increased risk of stent thrombosis. Our study focused on the effect of stent type on population-based interventional outcomes.
Objective To compare outcomes of Medicare beneficiaries who underwent nonemergent coronary stenting before and after the availability of drug-eluting stents.
Design, Setting, and Patients Observational study of 38 917 Medicare patients who underwent nonemergent coronary stenting from October 2002 through March 2003 when only bare-metal stents were available (bare-metal stent era cohort) and 28 086 similar patients who underwent coronary stenting from September through December 2003, when 61.5% of patients received a drug-eluting stent and 38.5% received a bare-metal stent (drug-eluting stent era cohort). Follow-up data were available through December 31, 2005.
Main Outcome Measures Coronary revascularization (percutaneous coronary intervention, coronary artery bypass surgery), ST-elevation myocardial infarction, survival through 2 years of follow-up.
Results Relative to the bare-metal stent era, patients treated in the drug-eluting stent era had lower 2-year risks for repeat percutaneous coronary interventions (17.1% vs 20.0%, P < .001) and coronary artery bypass surgery (2.7% vs 4.2%, P < .01). The difference in need for repeat revascularization procedures between these 2 eras remained significant after risk adjustment (hazard ratio, 0.82; 95% confidence interval, 0.79-0.85). There was no difference in unadjusted mortality risks at 2 years (8.4% vs 8.4%, P =.98 ), but a small decrease in ST-elevation myocardial infarction existed (2.4% vs 2.0%, P < .001). The adjusted hazard of death or ST-elevation myocardial infarction at 2 years was similar (hazard ratio, 0.96; 95% confidence interval, 0.92-1.01).
Conclusion The widespread adoption of drug-eluting stents into routine practice was associated with a decline in the need for repeat revascularization procedures and had similar 2-year risks for death or ST-elevation myocardial infarction to bare-metal stents.
Author Affiliations: Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, and the Department of Medicine, Dartmouth Medical School (Drs Malenka and Kaplan), The Dartmouth Institute for Health Policy and Clinical Practice (Drs Malenka, Lucas, and Skinner and Ms Sharp), and Department of Economics (Dr Skinner), Dartmouth College, Hanover, New Hampshire, and Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine (Dr Lucas).
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