Disparities In The Use Of Drug-eluting Stents For Diabetic Patients With ST-elevation Acute Myocardial Infarction Assisted In the Public versus Private Network - VICTIM Register / Disparidades no Uso de Stents Farmacológicos para Pacientes Diabéticos com Infarto Agudo do Miocárdio com Supradesnivelamento do Segmento ST Assistidos na Rede Pública versus Privada - Registro VICTIM

Abstract Background: Primary angioplasty (PA) with placement of either bare metal or drug-eluting stents (DES) represents the main strategy in the treatment of ST-elevation myocardial infarction (STEMI). Diabetic patients, however, represent a special population in STEMI, with high rates of restenosis and unfavorable clinical outcomes, and with the use of DES, level of evidence A and indication class II, being indicated to reduce these damages. Objectives: To evaluate the DES rate of use in patients with STEMI and in the subgroup of diabetics assisted in the public versus private health network in Sergipe. Methods: This is a population-based, cross-sectional study with a quantitative approach using the data from the VICTIM Register. These were collected in the only four hospitals with capacity to perform PA in Sergipe, from December 2014 to March 2017. Results: A total of 707 patients diagnosed with STEMI were evaluated, of which 589 were attended at SUS and 118 at the private network. The use of DES in PA was lower in SUS compared to the private network in both the total sample (10.5% vs 82.4%, p<0.001) and in subgroup diabetic patients (8.7% vs 90.6%, p < 0.001), respectively. In all hypotheses tested, the level of significance was 5% (p < 0.05). Conclusions: The study reveals a disparity in the use of DES during the performance of PA between the public and private network, both in the total sample and the subgroup for diabetics, with lower rates for SUS users, demonstrating the challenges that need to be overcome in order to achieve quality improvements of the services provided.

Resumo Fundamento: A angioplastia primária (AP) com colocação de stent, seja ele convencional ou farmacológico, representa a principal estratégia no tratamento do infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Os pacientes diabéticos, entretanto, representam população especial no IAMCSST, com altas taxas de reestenose e desfechos clínicos desfavoráveis, devendo-se indicar o uso de stents farmacológicos (SF), nível de evidência A e classe de indicação II, para redução destes danos. Objetivo: Avaliar a taxa de uso de SF em pacientes com IAMCSST e no subgrupo dos diabéticos assistidos na rede pública versus privada de saúde em Sergipe. Métodos: Trata-se de um estudo populacional, transversal, com abordagem quantitativa, que utilizou os dados do Registro VICTIM. Estes foram coletados nos quatro únicos hospitais com capacidade para realizar AP em Sergipe, no período de dezembro de 2014 a março de 2017. Em todas as hipóteses testadas, o nível de significância adotado foi de 5% (p < 0,05). Resultados: Foram avaliados 707 pacientes diagnosticados com IAMCSST, dos quais 589 foram atendidos pelo SUS e 118 pela rede privada. O uso de SF na AP foi menor no SUS em comparação com a rede privada, tanto no total da amostra (10,5% vs 82,4%; p < 0,001) quanto no subgrupo dos pacientes diabéticos (8,7% vs 90,6%; p < 0,001), respectivamente. Conclusões: O estudo revela disparidade no uso de SF durante a realização de AP entre a rede pública e privada, tanto na amostra total quanto no subgrupo dos diabéticos, com menores taxas para usuários do SUS, demonstrando os desafios que necessitam ser vencidos para se atingir melhorias na qualidade dos serviços prestados.

A Meta-analysis of Ostial and Trunk versus Distal Lesions in Unprotected Left Main Coronary Artery Stenting.

Aims: To assess outcomes for percutaneous coronary intervention (PCI) in ostial and trunk versus distal unprotected left main coronary artery (LMCA) lesions in the drugeluted stent (DES) era. Study Design: A meta-analysis and systematic review. Methods: With the help of a librarian, we searched Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and the Clinical Trials Registry from 2001 to July 2012. We included studies that enrolled ≥ 50 patients and had ≥6 months of follow-up. Our co-primary endpoints were the incidence of major adverse cardiac events (MACE) and target lesion/vessel revascularization (TLR/TVR). Data was abstracted and analyzed by two independent reviewers and differences were resolved by consensus. We assessed the results for heterogeneity in our analysis by examining the forest plots and then calculating a Q statistic, which we compared with the I2 index. If there was no evidence of statistical heterogeneity and pooling of results was clinically appropriate, a combined estimate was obtained using the fixed-effects model; otherwise the random-effects model was used. Results: We identified 11studies involving 3,718 patients. Mean duration of follow-up was 29 months (range 12-62months). Compared with ostial and trunk stenting, distal LMCA PCI was associated with increased MACE (OR 1.95, 95% CI 1.43-2.66) and TLR/TVR (OR 3.13, 95% CI 1.90-5.16).No significant differences were detected for cardiac death (OR 1.06, 95% CI 0.72-1.58, p=0.58), MI (OR 1.15, 95% CI 0.74-1.77, p=0.80) or stent thrombosis (OR 1.57, 95% CI 0.90-2.77, p=0.41). Conclusion: Patients with ostial and trunk LMCA lesions treated with DES have better outcomes than patients with distal lesions. Our findings may support unprotected nondistal LMCA stenting as a primary approach in selected patient subsets.

Are Biodegradable Third Generation Drug Eluting Stents the Answer to Instent Restenosis.

The third generation biodegradable Drug Eluting Stent (DES) are being evaluated and being introduced in clinical practice. They have been DESigned to overcome limitations associated with durable polymer and a persistent metallic stent scaffold which could be related to late target lesion revascularization (TLR) and very late stent thrombosis (VLST). Although a recent pooled data analysis found that biodegradable polymer stents were superior for TLR and VLST compared with first generation Sirolimus Eluting Stent (SES), superiority has not been demonstrated against second generation Everolimus eluting stents (EES) and is yet to be conclusively proven in randomized trials. This paper reviews the key features, recent trial data, and future directions of the third generation of DES technology including stents with fully biodegradable scaffolds, stents with biodegradable polymer, and polymer free stents.

Long-term outcomes of intravascular ultrasound-guided implantation of bare metal stents versus drug-eluting stents in primary percutaneous coronary intervention

BACKGROUND/AIMS: While drug-eluting stents (DESs) have shown favorable outcomes in ST-segment elevation myocardial infarction (STEMI) compared to bare metal stents (BMSs), there are concerns about the risk of stent thrombosis (ST) with DESs. Because intravascular ultrasound (IVUS) guidance may help optimize stent placement and improve outcomes in percutaneous coronary intervention (PCI) patients, we evaluated the impact of IVUS-guided BMS versus DES implantation on long-term outcomes in primary PCI. METHODS: In all, 239 STEMI patients received DES (n = 172) or BMS (n = 67) under IVUS guidance in primary PCI. The 3-year incidence of major adverse cardiac events (MACEs) including death, myocardial infarction (MI), target vessel revascularization (TVR), and ST was evaluated. RESULTS: There was no difference in all cause mortality or MI. However, the incidence of TVR was 23.9% with BMS versus 9.3% with DES (p = 0.005). Thus, the number of MACEs was significantly lower with DES (11.0% vs. 29.9%; p = 0.001). The incidence of definite or probable ST was not different (1.5% vs. 2.3%; p = 1.0). IVUS-guided DES implantation (hazard ratio [HR], 0.25; 95% confidence interval [CI], 0.08 to 0.78; p = 0.017), stent length (HR, 1.03; 95% CI, 1.00 to 1.06; p = 0.046), and multivessel disease (HR, 3.01; 95% CI, 1.11 to 8.15; p = 0.030) were independent predictors of MACE. CONCLUSIONS: In patients treated with primary PCI under IVUS guidance, the use of DES reduced the incidence of 3-year TVR versus BMS. However, all cause mortality and MI were similar between the groups. The incidence of ST was low in both groups.

In hospital and intermediate term outcome of percutaneous coronary intervention using drug eluting stents in elderly patients

Coronary artery disease [CAD] in elderly patients presents a challenging medical problem as regards diagnosis and management. Percutaneous coronary intervention [PCI] proved to be effective in restoring coronary blood flow regardless of patient age; however, the periprocedural risk is also increased due to complex lesion morphology. Durg eluting stent [DES] is an effective tool to avoid re-intervention in the elderly. Evaluation of PCI results in the elderly who received DES; both in hospital [before patient discharge] and up to 6months post procedure. Present study included 34 elderly patients aged >/= 65years old [group I] and 74 patients aged <65years old [group II] in the period from February 2007 to March 2008. All patients underwent coronary angiography and PCI and received at least one DES. Both patient groups were followed up in-hospital for procedure outcome and MACE and till 6 months post procedure in the outpatient clinic. Patient's characteristics, risk factors, and clinical presentation were evaluated and reported. Lesion number and morphology were recognized and classified according to ACC/AHA PCI guidelines. QCA analysis was performed before and after stent deployment to obtain the following: RVD, MLD, percent diameter stenosis, lesion length, and acute gain. The primary end points were death, MI, and target vessel revascularizarion [TVR]; the secondary end point was stent thrombosis according to the ARC definition. Patients were followed up clinically up to 6 months and the data were reported and compared in both groups. The mean age of group I patients was 69.5 +/- 3.7 years vs. 52.7 +/- 8.2 in group II. Both groups were matched with regards to gender distribution, ACS presentation, and major risk factors [p<0.05]. Associated co-morbid conditions such as renal failure, peripheral vascular diseases, and stroke were very low among the study population. The mean EF was 47 +/- 6 in both groups. The LAD was the most prevalent culprit vessel in both groups [61.8% in group I vs. 56.8% in group II, p=0.27]. The stent: lesion ratio was 1:1, and the stent: patient ratio was 1.4:1 in both groups. Taxus stent was the most commonly used DES in this study [54.5% in group I vs. 43.2% in group II] p>.0.05. The two groups had comparable distribution of type A, B, and C lesions. Tirofiban was used in only 21.2% in group I vs.13.5% I group II, p>0.05. The mean stent length was 19.6 +/- 7mm in group I vs.20.3 +/- 6mm in group II, p>0.05]. The mean stent size was 2.95 +/- 0.3mm in group I vs. 2.99 +/- 0.3mm in group II, p>0.05. The mean QCA analyses were comparable in both groups. The angiographic success was comparable in both groups [94.1% in group I vs. 98.6% in group II, p=0.28]. The procedural success was similar in both groups [94.1% in group I vs. 94.6% in groupII, P=0.5].The incidence of in-hospital MACE was low in both groups [3.1% in group I vs. 5.4% in group II, p>0.05]. Stroke rate was found in 1.4% in group II. The primary end points on 6 months follow up were 5.9% in group I vs. 6.8% in group II, p>0.05. Stent thrombosis and vascular complications were very low [1.4% for each] and found only in group II. With DES in the elderly is feasible, safe and effective compared with the younger age group. Patients with mild LV dysfunction, low associated co-morbid conditions and with even distribution of coronary lesion types have similar MACE post procedure. The primary end points within 6 months follow up are not significantly different from younger age groups