Drug-Eluting Versus Bare-Metal Stents in Unprotected Left Main Coronary Artery Stenosis

Abstract

Objectives We undertook a meta-analysis to assess outcomes for drug-eluting (DES) and bare metal stents (BMS) in percutaneous coronary intervention (PCI) for unprotected left main coronary stenosis (LMCA). Background Uncertainty exits regarding the relative performance of DES versus BMS in unprotected LMCA PCI. Methods Of a total of 838 studies, 44 met inclusion criteria (N=10,342). The co-primary endpoints were mortality, myocardial infarction (MI), target vessel/target lesion revascularization (TVR/TLR), and major adverse cardiac events (MACE: mortality, MI, TVR/TLR). Results Event rates for DES and BMS were calculated at 6–12 months, at 2 years and at 3 years. Crude event rates at 3 years were: mortality (8.8% and 12.7%), MI (4.0% and 3.4%), TVR/TLR (8.0% and 16.4%), and MACE (21.4% and 31.6%). Nine studies were included in a comparative analysis (N=5,081). At 6–12 months the adjusted odds ratio (OR) for DES vs. BMS were: mortality 0.94 (95% confidence interval [CI] 0.06–15.48; p=0.97), MI 0.64 (95% CI 0.19–2.17; p=0.47), TVR/TLR 0.10 (95% CI 0.01–0.84; p=0.01) and MACE 0.34 (95% CI 0.15–0.78; p=0.01). At 2 years the OR were: mortality 0.42 (95% CI 0.28–0.62; p<0.01), MI 0.16 (95% CI 0.01–3.53; p=0.13), and MACE 0.31 (95% CI 0.15–0.66; p<0.01). At 3 years the OR were: mortality 0.70 (95% CI 0.53–0.92; p=0.01), MI 0.49 (95% CI 0.26–0.92; p=0.03), TVR/TLR 0.46 (95% CI 0.30–0.69; p<0.01), and MACE 0.78 (95% CI 0.57–1.07; p=0.12). Conclusion Our meta-analysis suggests that DES is associated with favorable outcomes for mortality, MI, TVR/TLR, and MACE as compared to BMS in unprotected LMCA PCI.

Percutaneous Coronary Intervention vs. Coronary Artery Bypass Graft Surgery for Unprotected Left Main Coronary Artery Disease in the Drug-Eluting Stents Era

“…Our findings are contaminated by a sizeable use of BMS (12%) in the PCI arm, which was specifically shown to impart increased target vessel revascularization (TVR) compared with DES in patients with unprotected LMCA disease. 43, 45 After excluding studies with mixed BMS and DES use, our subanalysis demonstrated persistently higher rates of repeat revascularization in the PCI arm. The differences in repeat revascularization between PCI and CABG might also have been overestimated by the lack of even longer follow-up, when graft attrition becomes more apparent (as opposed to PCI-related restenosis, which usually occurs within the first year).…”

Randomized Trial of Stents versus Bypass Surgery for Left Main Coronary Artery Disease

“…[1][2][3][4][5][6][7][8][9][10][11] Recent clinical guidelines have accordingly stated that elective PCI can be considered for patients who have unprotected left main coronary artery disease, although they suggest that the aggregated evidence favors CABG. 12,13 Whether the outcomes after PCI are similar to those after CABG remains uncertain, however, owing to the lack of large, randomized clinical trials.…”

Percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease

“…The reason for the lower mortality rate in the DES group in that meta-analysis was not clear. It may be that the lower rates of restenosis in DES provides a true advantage over BMS (12). These data support a strategy of DES for LMCA PCI except in cases with large reference vessel diameter or in which long-term dual antiplatelet therapy is contraindicated.…”

“…A meta-analysis of observational studies and randomized controlled trials demonstrated lower crude event rates for DES than BMS for mortality, repeat revascularization, and MACE at six to 12 months, two years and three years (12). The reason for the lower mortality rate in the DES group in that meta-analysis was not clear.…”