What is the optimal stent strategy for coronary intervention in patients with high risk for bleeding in whom a short course of dual antiplatelet therapy is preferred?
In this meta-analysis of randomized clinical trials involving 3943 patients, we found that coronary intervention with drug-eluting stents decreased the risk for myocardial infarction, target vessel revascularization, ischemia-driven target lesion revascularization, and stent thrombosis compared with bare-metal stents used with 1 month of dual antiplatelet therapy.
In patients with high bleeding risk, coronary interventions with drug-eluting stents optimized for biocompatibility appear preferable over those with bare-metal stents.
A significant number of patients receive bare-metal stents (BMSs) instead of drug-eluting stents (DESs) to shorten the duration of dual antiplatelet therapy (DAPT). Emerging evidence suggests that new-generation DESs, particularly those optimized for biocompatibility, may be more efficacious and safer than BMSs, even with a single month of DAPT after stent implantation.
To evaluate the efficacy and safety of DESs compared with BMSs for coronary intervention with a single month of DAPT.
Human studies found in PubMed, the Cochrane databases through April 2018, and reference lists of selected articles.
Randomized clinical trials were included if they enrolled patients undergoing percutaneous coronary intervention and randomly assigned each patient to treatment with either DESs or BMSs. The additional inclusion criterion was use of only 1 month of DAPT poststent implantation.
Data Extraction and Synthesis
Two reviewers independently extracted the data. Odds ratios (ORs) were calculated using random-effects models.
Main Outcomes and Measures
The efficacy end points were major adverse cardiac events, myocardial infarction, target vessel revascularization, ischemia-driven target lesion revascularization, cardiac mortality, and all-cause mortality at 1 year. The safety outcomes were stent thrombosis and bleeding complications.
Data from 3 randomized clinical trials involving 3943 patients were included (2457 men [62.3%]; mean [SD] age ranging from 75.7 [9.3] years to 81.4 [4.3] years per trial subgroup). Coronary intervention with DESs reduced the rates for major adverse cardiac events (OR, 0.68 [95% CI, 0.57-0.82]; P < .001), target lesion revascularization (OR, 0.38 [95% CI, 0.22-0.67]; P = .001), target vessel revascularization (OR, 0.50 [95% CI, 0.38-0.65]; P < .001), and myocardial infarction (OR, 0.51 [95% CI, 0.31-0.83]; P = .01) compared with BMSs at 1 year. The incidence of stent thrombosis was also lower with DESs compared with BMSs (1.8% vs 2.8%), but this difference was not statistically significant in the random-effects model. Additionally, the 2 stent types did not differ in the risks of all-cause mortality, cardiac mortality, and bleeding.
Conclusions and Relevance
In the limited number of randomized clinical trials comparing DESs with BMSs with shortened DAPT durations in patients who have high bleeding risk or are uncertain candidates for prolonged DAPT, coronary intervention with specific DESs optimized for biocompatibility is not only safe but also efficacious, even with only 1 month of DAPT.
Shah R, Rao SV, Latham SB, Kandzari DE. Efficacy and Safety of Drug-Eluting Stents Optimized for Biocompatibility vs Bare-Metal Stents With a Single Month of Dual Antiplatelet TherapyA Meta-analysis. JAMA Cardiol. 2018;3(11):1050–1059. doi:10.1001/jamacardio.2018.3551
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