Long-term Outcomes in Patients Undergoing Percutaneous Coronary Intervention with Drug-eluting Stents

Roberta Rossini; Giuseppe Musumeci; Alessandro Aprile; Orazio Valsecchi

Disclosures

Expert Rev Pharmacoeconomics Outcomes Res. 2010;10(1):49-61. 

In This Article

Expert Commentary

  • DES are associated with significant long-term reductions in repeat revascularization, restenosis and TVR compared with BMS. The majority of registry studies and meta-analyses seem to have provided reassuring results regarding the long-term rates of death and MI associated with the use of DES compared with BMS;

  • In DES, stent thrombosis seems to appear as primary thrombosis, whereas in BMS, a certain number of late thromboses are related to repeat interventions of the target lesion. DES should be tested for superiority over BMS and not for noninferiority;

  • Large trials powered for clinical outcomes, including death and nonfatal MI, are direly needed to ensure that the frequent but rather benign restenosis has not been interpreted as the rare but unpredictable and potentially lethal late stent thrombosis;

  • Differences in the antiplatelet therapy given to patients receiving DES and BMS complicate the interpretation of the relative long-term benefit of stent type. The noninferiority of DES might be abolished by the prolongation of dual antiplatelet therapy in BMS as in DES patients;

  • DES require a prolonged dual antiplatelet therapy, which confers the patients a higher hemorrhagic risk;

  • The definition of MI should be more stringent, including only Q-MI. A small periprocedural MI does not have the same clinical implication as an MI owing to stent thrombosis. The exclusion of non-Q MI might reduce the rate of events in BMS where there is a higher rate of procedures due to in-stent restenosis;

  • Among the end points, TLR should be clinically driven, as it is in 'real world' patients, rather than angiographically driven. This would reduce the superiority of DES over BMS;

  • DES should be used in selected patients, with high risk of in-stent restenosis and low hemorrhagic risk.

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