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Bare-Metal and Drug-Eluting Stents: What’s the Bottom Line?

Results of a retrospective study of Medicare patients suggest that, on balance, drug-eluting stents have improved outcomes.

Several recent observational studies have addressed the trade-offs of using bare-metal stents (BMS) versus drug-eluting stents (DES) to treat coronary atherosclerosis (JW Cardiol Jun 4 2008). In this population-wide study of Medicare-eligible patients, investigators compared outcomes in 38,917 patients who received BMS from October 2002 through March 2003 with outcomes in 28,086 patients who received any stent from September through December 2003. In the latter group, 61.5% of the patients received DES (sirolimus-eluting only) and 38.5% received BMS.

Baseline characteristics of the two cohorts were similar, except for a slightly higher prevalence of diabetes in the DES era. After 2 years of follow-up, the rate of repeat revascularization was significantly lower in the DES era (19.0%) than in the BMS-only era (22.8%; adjusted hazard ratio, 0.82). The adjusted HR for death or ST-segment-elevation MI at 2 years showed a slight trend in favor of the DES era (0.96) that did not reach statistical significance. Similar results were found in subgroups based on sex, age, race, and presence of diabetes, as well as in a landmark analysis that excluded patients who experienced events in the first 3 months after the procedure.

Comment: This large observational study is better powered than were prior randomized studies to detect the consequences of a difference in stent thrombosis rates between drug-eluting and bare-metal stent recipients, and it may better reflect real-world use of these devices, including for off-label indications. These findings demonstrate a reduction after the introduction of DES in the repeat revascularization rate at 2 years, without any associated increase in death or STEMI rates. An increased risk for late stent thrombosis has been associated with DES in some studies; however, if such an increase occurred in this study, it was more than offset by a decrease in the risk for restenosis and events arising from its treatment.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology June 24, 2008

Citation(s):

Malenka DJ et al. Outcomes following coronary stenting in the era of bare-metal vs the era of drug-eluting stents. JAMA 2008 Jun 25; 299:2868.

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