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Published on: May 14, 2013
Coronary Calcification and Long-Term Outcomes According to Drug-Eluting Stent Generation
Paul Guedeney1, Bimmer E Claessen2, Roxana Mehran3
1The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), Paris, France.
Insights
Coronary artery calcification (CAC) increases risks after percutaneous coronary intervention. Second-generation drug-eluting stents (DES) significantly improve outcomes in patients with moderate or severe CAC compared to first-generation DES.
Area of Science:
- Cardiology
- Interventional Cardiology
- Biomedical Engineering
Background:
- Coronary artery calcification (CAC) is a common finding in patients undergoing percutaneous coronary intervention (PCI).
- The long-term impact of severe CAC on PCI outcomes and the comparative effectiveness of different generations of drug-eluting stents (DES) remain incompletely understood.
Purpose of the Study:
- To evaluate the long-term impact of moderate or severe CAC on patient-oriented and device-oriented composite endpoints after PCI.
- To compare the performance of first-generation versus second-generation DES in patients with and without moderate or severe CAC.
Main Methods:
- Pooled individual patient data from 18 randomized trials of DES implantation.
- Patients were categorized based on the presence of moderate or severe CAC confirmed by angiography.
- Five-year outcomes were assessed using multivariate Cox proportional regression, analyzing patient-oriented composite endpoints and target lesion failure.
Main Results:
- Moderate or severe CAC was present in 31.3% of patients and was associated with a significantly increased 5-year risk of adverse outcomes.
- Second-generation DES demonstrated a significant reduction in the 5-year risk of patient-oriented composite endpoints and target lesion failure compared to first-generation DES in patients with CAC.
- These benefits of second-generation DES were consistent across patient groups with and without moderate or severe CAC.
Conclusions:
- PCI in lesions with moderate or severe CAC is associated with adverse long-term outcomes.
- Second-generation DES mitigate the detrimental effects of CAC, offering improved patient and device outcomes compared to first-generation DES.
Objectives:
The aim of this study was to evaluate the long-term impact of coronary artery calcification (CAC) on outcomes after percutaneous coronary intervention and the respective performance of first- and second-generation drug-eluting stents (DES).
Background:
Whether contemporary DES have improved the long-term prognosis after percutaneous coronary intervention in lesions with severe CAC is unknown.
Methods:
Individual patient data were pooled from 18 randomized trials evaluating DES, categorized according to the presence of angiography core laboratory-confirmed moderate or severe CAC. Major endpoints were the patient-oriented composite endpoint (death, myocardial infarction [MI], or any revascularization) and the device-oriented composite endpoint of target lesion failure (cardiac death, target vessel MI, or ischemia-driven target lesion revascularization). Multivariate Cox proportional regression with study as a random effect was used to assess 5-year outcomes.
Results:
A total of 19,833 patients were included. Moderate or severe CAC was present in 1 or more target lesions in 6,211 patients (31.3%) and was associated with increased 5-year risk for the patient-oriented composite endpoint (adjusted hazard ratio [adjHR]: 1.12; 95% confidence interval [CI]: 1.05 to 1.20) and target lesion failure (adjHR: 1.21; 95% CI: 1.09 to 1.34), as well as death, MI, and ischemia-driven target lesion revascularization. In patients with CAC, use of second-generation DES compared with first-generation DES was associated with reductions in the 5-year risk for the patient-oriented composite endpoint (adjHR: 0.88; 95% CI: 0.78 to 1.00) and target lesion failure (adjHR: 0.73; 95% CI: 0.61 to 0.87), as well as death or MI, ischemia-driven target lesion revascularization, and stent thrombosis. The relative treatment effects of second-generation compared with first-generation DES were consistent in patients with and without moderate or severe CAC, although outcomes were consistently better with contemporary devices.
Conclusions:
In this large-scale study, percutaneous coronary intervention of target lesion moderate or severe CAC was associated with adverse patient-oriented and device-oriented adverse outcomes at 5 years. These detrimental effects were mitigated with second-generation DES.
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