Long-term outcomes with paclitaxel-eluting stents versus bare metal stents in everyday practice: a Canadian experience.

BACKGROUND: In randomized trials, paclitaxel-eluting stents (PES) are superior to bare metal stents (BMS) in reducing target lesion revascularization (TLR). However, recent reports suggest there may be an increase in late stent thrombosis with long-term follow-up in PES-treated patients. METHODS: Prospectively collected data from a regional cardiac referral centre were analyzed to compare PES versus BMS in all consecutive patients undergoing percutaneous coronary intervention from April 2003 to March 2004. Outcomes included combined death, myocardial infarction and clinically driven TLR, as well as stent thrombosis at four years follow-up. RESULTS: A total of 512 patients were treated with PES and 722 patients with BMS. At four years, there was 92% follow-up in both groups. The composite outcome of death, myocardial infarction and TLR was 13.9% in the PES group compared with 20% in the BMS group (P=0.01). This difference was primarily driven by the reduction in TLR in the PES cohort (3.9% versus 8%, P<0.01). The rate of definite stent thrombosis was 1.6% in the PES group compared with 0.4% in the BMS group (P=0.03). CONCLUSION: While PES offers an absolute 4.1% reduction in clinically driven TLR at four years, there is an associated increased risk of stent thrombosis. Further long-term studies addressing clinical outcomes including stent thrombosis with PES versus BMS are required to clarify this risk/ benefit balance.

Warfarin after anterior myocardial infarction in current era of dual antiplatelet therapy: a randomized feasibility trial.

UNLABELLED: In the current era of early revascularization and routine use of dual antiplatelet therapy, the incremental benefit of warfarin to reduce the incidence of left ventricular thrombus (LVT) in patients with impaired left ventricular ejection fraction post anterior ST-elevation myocardial infarction (aSTEMI), remains uncertain. The purpose of this study is to assess the feasibility of evaluating the added benefit and safety of triple therapy (TT-warfarin, ASA, and clopidogrel) versus dual therapy (DT-ASA and clopidogrel) in patients at risk of LVT post aSTEMI. DESIGN: Open-label randomized controlled trial. INCLUSION: aSTEMI, ejection fraction <40%, and no evidence of LVT. EXCLUSION: contraindication to, or alternate indication for anticoagulation. INTERVENTION: TT versus DT. FOLLOW-UP: pre-discharge and 3 month echocardiogram. OUTCOMES: composite of death, MI, stroke, systemic embolizarion, LVT or major bleeding at three months. 295 patients with aSTEMI were screened: 27% of patients with LVEF < 40% had an LVT; 20/52 eligible patients were randomized to receive TT (n = 10) or DT (n = 10). Baseline characteristics: mean age 60 years, male gender 65%, diabetics 20%, and in hospital PCI 95%. There was no significant difference in the composite endpoint at 3 months (TT-20% with 1 LVT and 1 major bleed versus DT-10% with 1 MI). The incidence of definite or probable LVT in the screened population of patients post aSTEMI with an LVEF < 40% was 26.6% despite 94% having early revascularization. STEMI patients have a high incidence of LVT despite the routine use of early revascularization and dual antiplatelet therapy. More effective antithrombotic strategies merit evaluation in adequately powered randomized trials.

Comparison of one-year clinical outcomes with paclitaxel-eluting stents versus bare metal stents in everyday practice.

BACKGROUND: In randomized trials, paclitaxel-eluting stents (PES) have been shown to be superior to bare metal stents (BMS) in reducing restenosis. However, the effectiveness of PES in patients treated during routine practice has not been fully established. METHODS: A retrospective comparison of PES with BMS in consecutive patients undergoing percutaneous coronary intervention (PCI) from April 2003 to March 2004 was conducted. Outcomes included the composite of death, myocardial infarction and target lesion revascularization (TLR) at one year, as well as stent thrombosis. RESULTS: A total of 512 patients were treated with PES, and 722 patients were treated with BMS. Patients in the PES group were more likely to receive stents that were 20 mm in length or longer (52.2% versus 33.3%, P<0.0001), 2.5 mm in diameter or smaller (29.1% versus 12.5%, P<0.0001) and implanted in bifurcation positions (15.4% versus 11.6%, P=0.02). At one year, the composite outcome of death, myocardial infarction and TLR was 6.1% in the PES group compared with 10.8% in the BMS group (P=0.004). The one-year rate of stent thrombosis was 0.59% in the PES group compared with 0.28% in the BMS group (P=0.4). CONCLUSIONS: Despite being used in higher-risk lesions, there was a lower rate of major cardiac events at one year in patients treated with PES, primarily driven by the reduction in TLR. Thus, the experience with PES in contemporary practice applied to a broader population appears to be consistent with the results reported in randomized trials.

Primary and rescue percutaneous coronary intervention with paclitaxel-eluting stent implantation in ST-elevation myocardial infarction.

We conducted a retrospective comparison of paclitaxel-eluting stents (PESs, n = 60) versus bare metal stents (BMSs, n = 137) in consecutive patients who underwent primary or rescue percutaneous coronary intervention over 1 year. The PES cohort had no in-stent thromboses and had a 65% (p = 0.02) decrease in the combined end point of death, recurrent myocardial infarction, and target vessel revascularization at 1 year compared with the BMS group. PES implantation appears to be safe and possibly superior to BMS implantation in terms of 1-year major cardiovascular outcomes in the setting of ST-elevation myocardial infarction.

Impact of routine in-hospital assessment of low-density lipoprotein levels and standardized orders on statin therapy in patients undergoing percutaneous coronary interventions.

BACKGROUND: Previous studies have shown that a significant proportion of patients undergoing percutaneous coronary intervention (PCI) are not receiving guideline-recommended statin therapy upon hospital discharge. We evaluated the impact of the implementation of routine cholesterol profile measurements and standardized orders post-PCI on the number of patients receiving statin therapy. METHODS: We conducted a prospective, observational study on all patients undergoing PCI in an urban teaching hospital from February 2002 to March 2003. Patient baseline characteristics, statin therapy pre- and post-PCI, and fasting lipid profiles were recorded as part of an ongoing PCI database. A similar cohort of patients undergoing PCI in the one-year time period immediately before the intervention was used as a comparison group. RESULTS: A total of 1,748 patients underwent PCI during the study period. Statin therapy was prescribed in 78% of patients pre-PCI and increased to 92% at hospital discharge. In the year before implementation of the standardized post-PCI orders, there was only a 5% absolute increase in statin use after PCI compared to a 14% absolute increase in the study time period (p = < 0.0001). Low-density lipoprotein (LDL) levels were available in 1,268 patients. The median LDL level was 2.08 mmol/L for patients on statin therapy versus 2.40 mmol/L for those not on statins. CONCLUSIONS: Routine assessment of LDL levels and lipid-lowering therapy at the time of PCI resulted in a further increase in statin use. However, approximately one-third of patients still had an LDL level above recommended guidelines for secondary prevention.