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Drug-Eluting or Bare-Metal Stents for Left Anterior Descending or Left Main Coronary Artery Revascularization
Raffaele Piccolo1, Kaare H Bonaa2, Orestis Efthimiou3
1Department of Advanced Biomedical Sciences University of Naples Federico II Naples Italy.
Insights
New-generation drug-eluting stents (DES) significantly reduce cardiac death or myocardial infarction compared to bare-metal stents (BMS) in left anterior descending (LAD) or left main (LM) artery disease. This benefit extends to reduced all-cause mortality in LAD/LM patients treated with DES.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Biomedical Engineering
Background:
- New-generation drug-eluting stents (DES) demonstrate improved outcomes over bare-metal stents (BMS), including reduced target-vessel revascularization.
- Emerging data suggest DES may also lower risks of myocardial infarction and cardiovascular mortality.
- The differential efficacy of DES versus BMS based on the specific coronary artery treated requires further investigation.
Purpose of the Study:
- To evaluate the comparative effectiveness of drug-eluting stents (DES) versus bare-metal stents (BMS) for coronary artery disease treatment.
- To specifically analyze treatment effects based on the target artery location: left anterior descending (LAD) and/or left main (LM) versus other coronary territories.
- To assess the impact on the composite outcome of cardiac death or myocardial infarction, and all-cause mortality.
Main Methods:
- Individual patient data meta-analysis from the Coronary Stent Trialist (CST) Collaboration.
- Inclusion of 26,024 patients from 19 randomized trials comparing DES versus BMS.
- Primary outcome: composite of cardiac death or myocardial infarction; analyzed using hazard ratios (HRs) with 95% confidence intervals (CIs).
Main Results:
- A significant interaction (P=0.024) was observed, indicating that the treatment effect of DES versus BMS differs by target vessel location.
- DES demonstrated a greater reduction in cardiac death or myocardial infarction compared to BMS in LAD/LM territories (HR, 0.76; 95% CI, 0.68-0.85) versus no-LAD/LM territories (HR, 0.93; 95% CI, 0.83-1.05).
- The benefit in LAD/LM disease was driven by lower cardiac death (HR, 0.83; 95% CI, 0.70-0.98) and myocardial infarction (HR, 0.74; 95% CI, 0.65-0.85). All-cause mortality also showed a benefit for DES in LAD/LM disease (HR, 0.86; 95% CI, 0.76-0.97).
Conclusions:
- New-generation drug-eluting stents (DES) provide a sustained reduction in cardiac death or myocardial infarction compared to bare-metal stents (BMS) when used for LAD or left main coronary stenoses.
- The findings support the use of DES in complex coronary artery disease involving the LAD or LM arteries due to superior long-term safety and efficacy.
- Treatment with DES in LAD/LM disease is associated with a significant reduction in all-cause mortality.
Abstract:
Background New-generation drug-eluting stents (DES) reduce target-vessel revascularization compared with bare-metal stents (BMS), and recent data suggest that DES have the potential to decrease the risk of myocardial infarction and cardiovascular mortality. We evaluated the treatment effect of DES versus BMS according to the target artery (left anterior descending [LAD] and/or left main [LM] versus other territories [no-LAD/LM]). Methods and Results The Coronary Stent Trialist (CST) Collaboration gathered individual patient data of randomized trials of DES versus BMS for the treatment of coronary artery disease. The primary outcome was the composite of cardiac death or myocardial infarction. Hazard ratios (HRs) with 95% CIs were derived from a 1-stage individual patient data meta-analysis. We included 26 024 patients across 19 trials: 13 650 (52.4%) in the LAD/LM and 12 373 (47.6%) in the no-LAD/LM group. At 6-year follow-up, there was strong evidence that the treatment effect of DES versus BMS depended on the target vessel (P-interaction=0.024). Compared with BMS, DES reduced the risk of cardiac death or myocardial infarction to a greater extent in the LAD/LM (HR, 0.76; 95% CI, 0.68-0.85) than in the no-LAD/LM territories (HR, 0.93; 95% CI, 0.83-1.05). This benefit was driven by a lower risk of cardiac death (HR, 0.83; 95% CI, 0.70-0.98) and myocardial infarction (HR, 0.74; 95% CI, 0.65-0.85) in patients with LAD/LM disease randomized to DES. An interaction (P=0.004) was also found for all-cause mortality with patients with LAD/LM disease deriving benefit from DES (HR, 0.86; 95% CI, 0.76-0.97). Conclusions As compared with BMS, new-generation DES were associated with sustained reduction in the composite of cardiac death or myocardial infarction if used for the treatment of LAD or left main coronary stenoses. Registration URL: https://www.crd.york.ac.uk/PROSPERO; Unique identifier: CRD42017060520.
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