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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Dr. Nicolas Werner
Prof. Michael Bohm
Patients presenting with AMI can be treated with BMS or DES. Several reasons argue for the use of BMS in AMI as firstline therapy: 1) In the acute situation careful evaluation of contraindications of DES are difficult to assess. 2) Compliance of patients to long-term dual platelet inhibition can hardly be foreseen, especially in these emergency patients. 3) Implantation of a device with delayed reendothelialisation properties in a milieu of activated platelets may not be preferable. 4) Potential restenosis can be safely treated with DES after a careful evaluation of contraindications.
Percutaneous coronary interventions (PCIs) have been shown to be superior for the treatment of acute myocardial infarction (AMI) compared to fibrinolytic or other non-invasive treatment strategies (1). Randomised trials showed a significant reduction in the rates of death and recurrent ischemia when using PCI compared to medial treatment in AMI. With the introduction of drug eluting stents (DES) into the market, the question appeared whether the use of DES instead of bare metal stents (BMS) would further improve the outcome of patients with AMI. The first randomised studies evaluating the role of DES in AMI became available in 2005 (2). Here we will discuss the role of DES in patients presenting with AMI which has been very recently suggested to be superior to BMS in an unselected, population based cohort of patients with myocardial infarction (3).
1) Randomised trials Numerous trials have investigated the role of DES compared to BMS in patients presenting with AMI (4). Within randomised trials, more than 3600 patients with AMI have been studied. Published trials were performed using paclitaxel- or sirolimus- eluting stents with various durations of clopidogrel treatment (3-12 months). In most trials the follow-up of patients was 12 to 24 months.
Meta-analyses (4;5) suggest that DES were :
2) A recently published study in an unselected, population based cohort of patients with myocardial infarction has challenged the results of the randomised trials (3). In this study, 7217 patients treated for STEMI and non-ST elevation AMI (NSTEMI) in Massachusetts hospitals between April 1, 2003 and September 30, 2004 were identified and assigned to either the DES or BMS group according to the stent type used during the acute intervention. The primary outcome was defined as death from any cause within 2 years after the initial procedure. Patients treated with DES (n=4016; 71% sirolimus eluting stents, 27% paclitaxel-eluting stents, 2% both) were slightly younger (63.6±13.4 versus 64.3±14.0, p=0.03) and suffered more frequently from diabetes, hyperlipidemia and hypertension. In contrast, patients receiving a BMS (n=3201) suffered more often from cardiogenic shock, ejection fraction below 30% and AMI with ST-segment elevation and had more often emergency procedures. To overcome these differences in treatment groups, a propensity-score model was applied. In this model, potential confounders (up to 63 including demographioc factors, medical history, risk factors etc.) were used to build a propensity-score and patients with similar scores were then matched. 2570 patients were matched and further analyses suggested a balance between treatment groups. Patients treated with DES had a significant lower mortality (primary endpoint) after 2 years compared to patients in the matched group receiving a BMS (NSTEMI and STEMI patients, 10.7% versus 12.8%, p=0.02). These results were also observed for patients with STEMI and patients with NSTEMI. Interestingly, the rates of reinfarction did not significantly differ in the total population of patients whereas a significant reduction in reinfarction was observed in patients with NSTEMI (12.8% versus 15.6%, p=0.04). In accordance with the published randomised controlled trials, target vessel revascularisation was significantly reduced in all groups (9.6% versus 14.5%, p<0.001).
Does these analyses change our strategy in patients with AMI? The question arises from the available data whether we should use DES as a preferable strategy in patients presenting with AMI.
Inclusion of propensity scores can help to reduce large biases, but significant biases may remain especially since unobserved confounders can not be included into the statistical model. Therefore, only large randomised trials with adequate follow-up will allow us to adequately address the question whether DES treatment has benefits concerning mortality rates compared to BMS. For the moment, patients presenting with AMI should be treated with BMS. The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.
1. Mehta SR, Cannon CP, Fox KA, Wallentin L, Boden WE, Spacek R, Widimsky P, McCullough PA, Hunt D, Braunwald E, Yusuf S. Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA. 2005;293:2908-2917. 2. Valgimigli M, Percoco G, Malagutti P, Campo G, Ferrari F, Barbieri D, Cicchitelli G, McFadden EP, Merlini F, Ansani L, Guardigli G, Bettini A, Parrinello G, Boersma E, Ferrari R. Tirofiban and sirolimus-eluting stent vs abciximab and bare-metal stent for acute myocardial infarction: a randomized trial. JAMA. 2005;293:2109-2117. 3. Mauri L, Silbaugh TS, Garg P, Wolf RE, Zelevinsky K, Lovett A, Varma MR, Zhou Z, Normand SL. Drug-eluting or bare-metal stents for acute myocardial infarction. N Engl J Med. 2008;359:1330-1342. 4. De Luca G, Stone GW, Suryapranata H, Laarman GJ, Menichelli M, Kaiser C, Valgimigli M, Di Lorenzo E, Dirksen MT, Spaulding C, Pittl U, Violini R, Percoco G, Marino P. Efficacy and safety of drug-eluting stents in ST-segment elevation myocardial infarction: A meta-analysis of randomized trials. Int J Cardiol. 2008. 5. Kastrati A, Dibra A, Spaulding C, Laarman GJ, Menichelli M, Valgimigli M, Di Lorenzo E, Kaiser C, Tierala I, Mehilli J, Seyfarth M, Varenne O, Dirksen MT, Percoco G, Varricchio A, Pittl U, Syvanne M, Suttorp MJ, Violini R, Schomig A. Meta-analysis of randomized trials on drug-eluting stents vs. bare-metal stents in patients with acute myocardial infarction. Eur Heart J. 2007;28:2706-2713.
Dr. N. Werner1 and Prof. M. Böhm2* 1Bonn and 2Homburg-Saar, Germany. *Nucleus member of Heart Failure Association of the ESC.