Rates of stent thrombosis in bare-metal versus drug-eluting stents (from a large Australian multicenter registry).

Recent reports suggest that drug-eluting stents (DESs) may increase the risk of stent thrombosis (ST) relative to bare-metal stents (BMSs). Therefore, the aim of this study was to compare DES and BMS outcomes with a specific focus on ST. We analyzed 30-day and 1-year outcomes of 2,919 patients who underwent percutaneous coronary intervention with stent implantation from the Melbourne Interventional Group registry. Academic Research Consortium definitions of ST were used: (1) definite ST (confirmed using angiography in patients with an acute coronary syndrome), (2) probable ST (unexplained death <30 days or target-vessel myocardial infarction without angiographic confirmation), and (3) possible ST (unexplained death >30 days). Multivariate analysis was performed to identify predictors of ST. The incidence of ST (early or late) was similar between BMSs and DESs (1.6% vs 1.4%; p=0.66), and DES use was not predictive of ST. Independent predictors of ST included the absence of clopidogrel therapy at 30 days (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.29 to 5.29, p<0.01), renal failure (OR 3.30, 95% CI 1.43 to 7.59, p<0.01), index procedure presentation with an acute coronary syndrome (OR 2.59, 95% CI 1.14 to 5.87, p=0.02), diabetes mellitus (OR 2.25, 95% CI 1.19 to 4.23, p=0.01), and total stent length >or=20 mm (OR 1.85, 95% CI 1.00 to 3.42, p=0.04). In conclusion, DESs were not associated with increased risk of ST compared with BMSs at 12 months in this large Australian registry that selectively used DESs for patients at high risk of restenosis.

An evaluation of octogenarians undergoing percutaneous coronary intervention from the Melbourne Interventional Group registry.

OBJECTIVES: The objective of this study was to evaluate the clinical characteristics and outcomes of octogenarians (> or =80 years of age) in a contemporary, multi-centre percutaneous coronary intervention (PCI) registry. BACKGROUND: Octogenarians are increasingly referred for PCI. This patient population frequently has significant comorbidities, which result in major therapeutic challenges. METHODS: The study population consisted of consecutive patients undergoing PCI in seven major Australian hospitals, who were treated over a 2-year period (2004-2005). RESULTS: Of 4,360 PCI's, 11.3% (n = 491) were performed in octogenarians and 88.7% (n = 3,869) in patients <80 years. Octogenarians (compared with patients <80 years of age) were more likely female and have greater comorbidities such as cerebrovascular disease, renal impairment, congestive heart failure, and chronic airway disease. Octogenarians more frequently presented with acute coronary syndromes and cardiogenic shock. Octogenarians had significantly increased 30-day (6.0 vs. 1.4%, P < 0.01) and 12-month mortality (8.4% vs. 2.5%, P < 0.01), and major adverse cardiac event rates [(MACE), 30 days 11.3% vs. 5.4%, P < 0.01 and 12-months 18.7% vs. 12.9%, P = 0.04]. Cardiogenic shock, ST-segment elevation myocardial infarction, chronic renal failure, and age > or =80 years were independent predictors of 12-month mortality. CONCLUSIONS: Octogenarians comprise a significant cohort of patients undergoing PCI. Octogenarians have more comorbidities, and higher rates of mortality and MACE, mandating thorough clinical evaluation before acceptance for PCI.

Use of drug-eluting stents in Victorian public hospitals.

OBJECTIVE: We aimed to assess the pattern of use of drug-eluting stents (DESs) in patients undergoing percutaneous coronary interventions (PCIs) in Victorian public hospitals. DESIGN, SETTING AND PATIENTS: Prospective study comparing the use of one or more DESs versus bare-metal stents (BMSs) only, in consecutive patients undergoing 2428 PCIs with stent implantation from 1 April 2004 to 31 December 2005 at seven Victorian public hospitals. MAIN OUTCOME MEASURES: Adherence to current Victorian Department of Human Services guidelines which recommend DES use in patients with high-risk features for restenosis (diabetes, small vessels, long lesions, in-stent restenotic lesions, chronic total occlusions and bifurcation lesions). RESULTS: Of the 2428 PCIs performed, at least one DES was implanted in 1101 (45.3%) and BMSs only were implanted in 1327 (54.7%). In 87.7% (966/1101) of PCI with DESs, there was at least one criterion for high risk of restenosis. DESs were more likely to be used in patients with diabetes (risk ratio [RR], 2.45; 95% CI, 2.02-2.97), small vessels (RR, 3.35; 95%CI, 2.35-4.76), long lesions (RR, 3.87; 95% CI, 3.23-4.65), in-stent restenotic lesions (RR, 3.98; 95%CI, 2.67-6.06), chronic total occlusions (RR, 1.30; 95% CI, 0.51-2.88) and bifurcation lesions (RR, 2.23; 95%CI, 1.57-3.17). However, 66.2% (1608/2428) of all PCIs were in patients eligible for DESs according to Victorian guidelines, and in 39.9% (642/1608) of these PCIs, a BMS was used. CONCLUSION: In Victorian public hospitals, DESs have been largely reserved for patients at high risk of restenosis in accordance with Department of Human Services guidelines. However, many patients with high-risk criteria for restenosis did not receive DESs. Greater use of DESs in these patients may improve outcomes by reducing the need for repeat revascularisation.

The clinical outcome of restricting drug-eluting stents to patients at highest risk of restenosis.

AIMS: To assess the clinical outcomes of patients where drug eluting stents (DES) were restricted to those at highest risks of restenosis, we compared three different strategies for stent implantation: bare metal stents (BMS) only, DES only and a group where DES use was restricted (RES). METHOD AND RESULTS: Initial comparison was made between BMS only (279 patients, 316 lesions) and DES only (272 patients, 302 lesions). The endpoints of death, non-fatal myocardial infarction and target lesion revascularisation (TLR) [MACE] were assessed at 12 months. The incidence of MACE in the BMS only and DES only groups were 14% and 7% (p=0.002) and TLR was 8% and 1% (p<0.0001). Comparison was then made between these results and a third group where DES was restricted to patients at highest risk of restenosis. The restricted group (RES) comprised 249 patients (271 lesions) of which 53% received DES. RES remained significantly better than BMS, MACE (14% vs. 8%, p=0.02) and TLR (8% vs. 3%, p=0.02). When RES was compared with DES only, there was no significant difference in MACE (8% vs. 7% p=0.42), but there was a significantly lower TLR rate in the DES only group (1% vs. 3% p=0.04). CONCLUSIONS: The overall incidence of events in patients where DES use was restricted to 53% of patients remains low and this may be an acceptable treatment strategy to reduce costs.