Effectiveness and Safety of Drug-Eluting Stents in Ontario

Tu, Jack V.; Bowen, James M.; Chiu, Maria; Ko, Dennis T.; Austin, Peter C.; He, Yaohua; Hopkins, Robert; Tarride, Jean‐Éric; Blackhouse, Gord; Lazzam, Charles; Cohen, Éric A.; Goeree, Ron

doi:10.1056/nejmoa071076

Cited by 355 publications

(280 citation statements)

References 29 publications

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“…While the superiority of DES in reducing target vessel revascularization is well established, the observation that DES are associated with improved survival has not been substantiated in randomized trials that eliminate selection bias. However, recently published registries have reported similar data in Ontario (12) and Massachusetts (13) (13) reported a mortality benefit at two years. Evidently, any absolute mortality benefit attributable to DES would need to be confirmed by a randomized study with long-term follow-up.…”

Section: Figure 1) Kaplan-meier Curve Estimating Overall Survival Esmentioning

confidence: 62%

Late outcomes following percutaneous coronary interventions: Results from a large, observational registry

Appleby¹,

Mackie²,

Džavík³

et al. 2010

Canadian Journal of Cardiology

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T he introduction of coronary stent implantation heralded a major advance in percutaneous coronary intervention (PCI), with dramatically improved in-hospital mortality and morbidity compared with plain old balloon angioplasty for the treatment of coronary artery disease. Several randomized controlled trials (RCTs) have established the superior long-term safety and efficacy of bare-metal stenting (BMS) compared with plain old balloon angioplasty (1-3). The introduction of drug-eluting stents (DES) resulted in a further significant reduction in restenosis, and has been associated with improved procedural outcomes in a more complex subset of patients and lesions (4-7). Thus, coronary stenting using bare-metal or drug-eluting platforms has become the cornerstone of PCI, and the indications for PCI have vastly expanded beyond those originally proposed.Pooled data from randomized DES trials have shown acceptable rates of all-cause mortality, myocardial infarction (MI) and revascularization in extended follow-up, up to four years (8). Although RCTs have excellent internal validity, direct extrapolation of their findings to the general population has been problematic due to their restrictive inclusion and exclusion criteria. Early data (9,10) regarding clinical outcomes in real-world patient reports from registries had limitations in both the follow-up period and the patient cohort size; the large New York State registry (11) comparing three-year outcomes in patients undergoing coronary stenting versus coronary artery bypass graft (CABG) surgery excluded all those with previous revascularization, left main stem (LMS) disease or MI within 24 h of the index procedure (11). More recently, several registries have compared two-(6,12-14) or three-year (15) outcomes in patients undergoing BMSonly versus DES-only PCI, and confirmed higher rates of subsequent revascularization in BMS-treated patients with either lower (12-14) or equivalent (6) rates of mortality or MI in DES-treated patients, or a HeaLtH outcomes/pubLic poLicy ©2010 Pulsus Group Inc. All rights reserved BACKgRounD: Randomized controlled trials report short-and medium-term outcomes following percutaneous coronary intervention (PCI), but their applicability to the general population is not known. Data regarding the long-term clinical outcomes of patients undergoing PCI are lacking. oBJECTIVE: To determine the long-term outcomes of 'all-comers' undergoing PCI at a large-volume tertiary cardiac referral centre. METhoDs: A total of 12,662 consecutive patients undergoing an index procedure and entered into the University Health Network's (Toronto, Ontario) prospective registry between April 2000 and September 2007 were identified. In-hospital outcomes were assessed. Follow-up data were obtained through linkage to a provincial registry. Kaplan-Meier analysis was performed to calculate unadjusted survival rates, and Cox multiple regression analysis identified independent predictors of late mortality, major adverse cardiac events and all cardiovascular events. REsuLTs: T...

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Section: Figure 1) Kaplan-meier Curve Estimating Overall Survival Esmentioning

confidence: 62%

Late outcomes following percutaneous coronary interventions: Results from a large, observational registry

Appleby¹,

Mackie²,

Džavík³

et al. 2010

Canadian Journal of Cardiology

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“…The Cardiac Care Network (CCN) of Ontario Cardiac Registry was used to determine receipt of angiography, obstructive CAD status on angiography, and patient clinical covariate status. The CCN Cardiac Registry is an ongoing prospective registry storing clinical information on all invasive cardiac procedures in Ontario and has been used extensively in clinical research 20, 21, 22, 23. The registry contains detailed demographic, comorbidity, and procedural details, including coronary anatomy, that have been validated against chart abstraction and core laboratory verification 24, 25.…”

Section: Methodsmentioning

confidence: 99%

Comparison of Anatomic and Clinical Outcomes in Patients Undergoing Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease

Roifman

Wijeysundera

Austin

et al. 2017

JAHA

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BackgroundThe optimal initial noninvasive diagnostic testing strategy for stable coronary artery disease (CAD) is unknown. Although American guidelines recommend an exercise stress test as the first‐line test, European guidelines suggest that stress imaging (myocardial perfusion imaging or stress echocardiography) or coronary computed tomography angiography may be preferable. Understanding the relationship between the initial strategy and downstream yield of obstructive CAD and major adverse cardiac events may provide insight as to the optimal strategy.Methods and ResultsWe conducted a population‐based retrospective cohort study of adults in Ontario, Canada, using health administrative and clinical data. The relationship between the initial testing strategy and obstructive CAD on invasive angiography was examined. Patients were then followed from their angiogram onward to determine whether they developed a composite end point of major adverse cardiac events. After adjusting for covariates, patients with initial myocardial perfusion imaging (odds ratio: 0.92; 95% confidence interval, 0.85, 1.00), coronary computed tomography angiography (odds ratio: 1.51; 95% confidence interval, 0.91, 2.49), or stress echo (odds ratio: 0.95; 95% confidence interval, 0.84, 1.08) did not a have significantly different yield of obstructive CAD compared with those with an initial exercise stress test. Furthermore, there was no significant difference in downstream major adverse cardiac events after invasive angiography among the 4 initial testing strategies after adjusting for clinically relevant covariates.ConclusionsOur study found no evidence to suggest significant differences in either yield of obstructive CAD or downstream major adverse cardiac events in patients undergoing an initial noninvasive testing strategy with stress or anatomical imaging compared with those undergoing an initial exercise stress test.

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“…Assim, a estimativa do risco de novas RVA em populações tratadas contemporaneamente em nosso meio adquire importância para estimar seu potencial emprego na prática clínica diária caso venha a ser adotada. Como o principal benefício clínico dos stents farmacológicos consiste na diminuição da reestenose e de novos procedimentos de revascularização, seu uso preferencialmente naqueles pacientes propensos a esses desfechos parece ser a alternativa mais adequada dentro desse contexto, o que também foi demonstrado em alguns estudos recentes 8,17 .…”

Section: Discussionunclassified

“…Essa é uma característica importante desses dispositivos, já que a reestenose está associada a piora da qualidade de vida e a síndromes coronarianas agudas em alguns pacientes [4][5][6] . Além disso, estudos recentes têm demonstrado que os stents farmacológicos não estão associados a risco aumentado de morte e infarto do miocárdio (IAM) na maioria das situações clínicas e angiográficas e quando terapia antiplaquetária dupla adequada é instituída e mantida [7][8][9][10] . Nesse contexto, questões financeiras parecem ser o maior problema para que os stents farmacológicos sejam utilizados em maior número de pacientes, já que são significativamente mais caros que os stents convencionais.…”

Section: Descriptorsunclassified

Perfil de risco de reestenose em pacientes submetidos a implante de stents coronarianos convencionais

Quadros

Gottschall

Diemer

et al. 2008

Rev. Bras. Cardiol. Invasiva

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Effectiveness and Safety of Drug-Eluting Stents in Ontario

Abstract: Drug-eluting stents are effective in reducing the need for target-vessel revascularization in patients at highest risk for restenosis, without a significantly increased rate of death or myocardial infarction.

Cited by 355 publications

References 29 publications

Late outcomes following percutaneous coronary interventions: Results from a large, observational registry

Late outcomes following percutaneous coronary interventions: Results from a large, observational registry

Comparison of Anatomic and Clinical Outcomes in Patients Undergoing Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease

Perfil de risco de reestenose em pacientes submetidos a implante de stents coronarianos convencionais

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