Drug-eluting stents versus bare-metal stents in patients with decreased GFR: a meta-analysis
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Published on: May 14, 2013
Zhi Jian Wang1, Kishore J Harjai, Chetan Shenoy
1Department of Cardiology, Anzhen Hospital, Capital Medical University, Beijing, China.
Insights
Drug-eluting stents (DESs) significantly reduce repeat revascularization and myocardial infarction in patients with reduced kidney function (eGFR <60 mL/min/1.73 m(2)). DESs show a mortality benefit over bare-metal stents (BMSs), warranting further randomized trials.
Area of Science:
- Cardiology
- Nephrology
- Interventional Cardiology
Background:
- Decreased estimated glomerular filtration rate (eGFR) is a significant predictor of adverse outcomes post-percutaneous coronary intervention (PCI).
- The comparative safety and efficacy of drug-eluting stents (DESs) versus bare-metal stents (BMSs) in patients with reduced eGFR remain inadequately evaluated.
Purpose of the Study:
- To systematically review and meta-analyze clinical outcomes comparing DESs and BMSs in patients with eGFR <60 mL/min/1.73 m(2).
Main Methods:
- A systematic review and meta-analysis of comparative studies.
- Searched MEDLINE, EMBASE, and Cochrane Library (2002-2013) for studies comparing DESs and BMSs in patients with eGFR <60 mL/min/1.73 m(2), excluding ST-segment elevation myocardial infarction exclusively.
- Extracted data on mortality, repeat revascularization, myocardial infarction, and stent thrombosis.
Main Results:
- Included 26 studies with 66,840 patients.
- DESs significantly reduced repeat revascularization (OR, 0.61) and myocardial infarction (OR, 0.85) compared to BMSs.
- No significant difference in stent thrombosis (OR, 0.72); DESs showed a significant reduction in mortality (OR, 0.77), though this benefit was attenuated in higher-quality studies.
Conclusions:
- DES use in patients with eGFR <60 mL/min/1.73 m(2) is associated with reduced repeat revascularization and myocardial infarction without increased stent thrombosis risk.
- The observed survival benefit of DESs requires confirmation through robust randomized controlled trials.
- Further research, particularly RCTs, is needed to definitively establish the mortality benefit of DESs over BMSs in this vulnerable population.
Background:
Decreased estimated glomerular filtration rate (eGFR) is a strong predictor of both mortality and subsequent cardiac events after percutaneous coronary intervention. The safety and efficacy of drug-eluting (DESs) versus bare-metal stents (BMSs) in this population have not been evaluated adequately.
Study Design:
A systematic review and meta-analysis.
Setting & Population:
Studies involving the comparison of clinical outcomes between DESs and BMSs in patients with eGFR <60 mL/min/1.73 m(2). Studies exclusively involving patients with ST-segment elevation myocardial infarction were excluded.
Selection Criteria For Studies:
MEDLINE (on Ovid), EMBASE, and the Cochrane Library databases from 2002-2013 were searched for studies comparing DESs with BMSs in patients with eGFR <60 mL/min/1.73 m(2).
Intervention:
DES versus BMS implantation.
Outcomes:
Mortality, repeat revascularization, myocardial infarction, and stent thrombosis.
Results:
Data from 26 comparative studies with 66,840 patients were included. Compared with BMSs, DESs were associated with significant reductions in repeat revascularization (OR, 0.61; 95% CI, 0.50-0.74; P < 0.001) and myocardial infarction (OR, 0.85; 95% CI, 0.79-0.92; P < 0.001), with no detectable difference in stent thrombosis (OR, 0.72; 95% CI, 0.46-1.12; P = 0.1). The superiority of DESs over BMSs in decreasing mortality also was documented (OR, 0.77; 95% CI, 0.65-0.90; P = 0.01). This survival benefit of DESs over BMSs was attenuated in randomized controlled trials or adjusted observational studies versus unadjusted observational studies.
Limitations:
Most studies were observational studies. Meta-analysis was not performed on individual patient data.
Conclusions:
DES use in patients with eGFR <60 mL/min/1.73 m(2) is associated with a reduced rate of repeat revascularization and myocardial infarction without increased risk of stent thrombosis. The true effect of DESs versus BMSs on mortality needs to be confirmed by randomized controlled trials.
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