Second versus first generation DES in multiple vessel disease and unprotected left main stenosis: insights from ERACI...

Recent data from randomized clinical trials (RCT) between PCI with first generation drug-eluting stent (DES) versus coronary artery bypass graft (CABG) showed a lack of benefit in the incidence of death and myocardial infarction (MI) with PCI. However in the last years a large improvement in the DES platforms was seen and was translated to a significant increase in safety and efficacy observed in RCT and observational studies. However, at present time little is known about the role of second generation DES in patients with complex multiple vessel coronary artery disease (CAD). ERACI IV registry is a multicenter, prospective and controlled open label study that evaluates a second generation DES, for the treatment of patients with multiple vessel CAD including unprotected left main. End point was to compare major adverse cardiovascular events (MACCE) and each component of them with previous arms of ERACI III study, first generation DES and CABG. ERACI IV compared to ERACI III DES arm, had greater number of diabetics (p = 0.02), at rest unstable angina (P = 0.01), 3 vessels plus left main (P = 0.02) and also more stent length per patient (P = 0.03).In ERACI IV 66.2% of patients had intermediate or high Syntax score. At one year, patients treated with 2nd generation compared to 1st generation DES had lower incidence of death (0.4% vs. 3.1% 4 P = 0.03), death/MI/stroke (0.9 vs. 6.7% P = 0.001), unplanned revascularization (1.8% vs. 8.9%, P = 0.001) and MACCE (2.2% vs. 12% P ≤ 0.001). Advantages was also observed in diabetics, MI (0% vs. 8.5 P = 0.05), death/MI/stroke (0% vs. 12.8%, P = 0.009), unplanned revascularization (1.4% vs. 14.9%, P = 0.01) and MACCE (1.4% vs. 21.3%, P < 0.001). In ERACI IV diabetic and non-diabetics had similar MACCE (1.4% vs. 2.6 %, P = 0.97). In conclusion, at one-year follow-up patients treated with second generation DES showed a remarkable low incidence of MACCE and any component of them; benefit was also seen in diabetics.