Unrestricted Use of Drug-Eluting Stents Compared With Bare-Metal Stents in Routine Clinical Practice

Abbott, J. Dawn; M, Voss; Nakamura, Mamoo; Cohen, Howard A.; Selzer, Faith; Kip, Kevin E.; Vlachos, Helen; Wilensky, Robert L.; Williams, David O.

doi:10.1016/j.jacc.2007.07.071

Cited by 85 publications

(58 citation statements)

References 30 publications

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“…Indeed, more than half of all DES implants are performed for "off-label" or "unproven" indications. [7][8][9] These use patterns, coupled with emerging safety concerns, have led to substantial interest in comparative effectiveness studies of DESs versus bare metal stents (BMSs) in routine clinical practice. 10 -12 These studies, based on observational data, have generally confirmed the benefits of DESs on clinical restenosis and the need for repeat revascularization that were seen in the original clinical trials.…”

Section: Editorial See P 581mentioning

confidence: 99%

Survival Benefit With Drug-Eluting Stents in Observational Studies

Venkitachalam

Lei

Magnuson

et al. 2011

Circ: Cardiovascular Quality and Outcomes

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2004 -2006 versus 2007) as the instrument, demonstrated no significant difference in 1-year mortality (predicted absolute difference, 2.0%; 95% CI, -1.8% to 5.7%; Pϭ0.30) and a strong trend toward reduced TLR with DES use (predicted absolute difference, -4.2%; 95% CI, -8.8% to 0.4%; Pϭ0.07). Conclusions-Among unselected PCI patients in contemporary practice, DES use tended to be associated with a consistent reduction in TLR regardless of risk-adjustment method but showed discordant effects on mortality with conventional risk adjustment compared with instrumentable variable analysis. These findings underscore the limitations of standard risk-adjustment methods to adequately address treatment selection bias in nonrandomized studies and have important implications for comparative effectiveness research using observational data. (Circ Cardiovasc Qual Outcomes. 2011;4:587-594.)

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Section: Editorial See P 581mentioning

confidence: 99%

Survival Benefit With Drug-Eluting Stents in Observational Studies

Venkitachalam

Lei

Magnuson

et al. 2011

Circ: Cardiovascular Quality and Outcomes

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“…In the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Percutaneous Coronary Intervention (PCI) Registry, the prevalence of diabetes increased from 23% in 1997 to 1999 to 31% in 2004. 2,3 Similarly, in the Nationwide Inpatient Sample, the percentage of patients undergoing coronary artery bypass graft (CABG) having diabetes increased from 16.7% in 1988 to 1990 to 33.9% from 2003 to 2005. 4 Patients with type 2 diabetes mellitus (T2DM), compared with those without diabetes, have a greater and more extensive atherosclerotic burden associated with impaired compensatory remodeling of the arterial wall.…”

mentioning

confidence: 99%

Impact of Completeness of Revascularization on Long-Term Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus

Schwartz

Bertolet

Feit

et al. 2012

Circ: Cardiovascular Interventions

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Background-Patients with diabetes have more extensive coronary disease than those without diabetes, resulting in more challenging percutaneous coronary intervention or surgical (coronary artery bypass graft) revascularization and more residual jeopardized myocardium. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial provided an opportunity to examine the long-term clinical impact of completeness of revascularization in patients with diabetes. Methods and Results-This is a post hoc, nonrandomized analysis of the completeness of revascularization in 751 patients who were randomly assigned to early revascularization, of whom 264 underwent coronary artery bypass graft surgery and 487 underwent percutaneous coronary intervention. The completeness of revascularization was determined by the residual postprocedure myocardial jeopardy index (RMJI). RMJI is a ratio of the number of myocardial territories supplied by a significantly diseased epicardial coronary artery or branch that was not successfully revascularized, divided by the total number of myocardial territories. Mean follow-up for mortality was 5.3 years. Complete revascularization (RMJIϭ0) was achieved in 37.9% of patients, mildly incomplete revascularization (RMJI Ͼ0Յ33) in 46.6%, and moderately to severely incomplete revascularization (RMJI Ͼ33) in 15.4%. Adjusted event-free survival was higher in patients with more complete revascularization (hazard ratio, 1.14; Pϭ0.0018). Conclusions-Patients

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“…Numerous randomized trials and observational studies have demonstrated significant reductions in clinical and angiographic restenosis compared with bare metal stents (BMS), [1][2][3][4][5] leading to widespread use of DES in both approved and "off-label" applications. 5,6 Nonetheless, several critical questions regarding DES remain unresolved.…”

mentioning

confidence: 99%

Clinical and Economic Outcomes of Liberal Versus Selective Drug-Eluting Stent Use

Venkitachalam¹,

Lei²,

Stolker³

et al. 2011

Circulation

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Background-Although the benefits of drug-eluting stents (DES) for reducing restenosis after percutaneous coronary intervention are well established, the impact of alternative rates of DES use on population-level outcomes is unknown. One-year rates of death or myocardial infarction were similar in both eras. Over this time period, the incidence of target lesion revascularization increased from 4.1% to 5.1%, an absolute increase of 1.0% (95% confidence interval, 0.1 to 1.9; Pϭ0.03), whereas total cardiovascular costs per patient decreased by $401 (95% confidence interval, 131 to 671; Pϭ0.004). The risk-adjusted incremental cost-effectiveness ratio for the liberal versus selective DES era was $16 000 per target lesion revascularization event avoided, $27 000 per repeat revascularization avoided, and $433 000 per quality-adjusted life-year gained. Conclusions-In this prospective registry, a temporal reduction in DES use was associated with a small increase in target lesion revascularization and a modest reduction in total cardiovascular costs. These findings suggest that although clinical outcomes are marginally better with unrestricted DES use, this approach represents a relatively inefficient use of healthcare resources relative to several common benchmarks for cost-effective care.

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Unrestricted Use of Drug-Eluting Stents Compared With Bare-Metal Stents in Routine Clinical Practice

Abstract: The generalized use of DES resulted in better outcomes than BMS, with fewer clinically driven revascularization procedures and similar rates of death and MI at 1 year.

Cited by 85 publications

References 30 publications

Survival Benefit With Drug-Eluting Stents in Observational Studies

Survival Benefit With Drug-Eluting Stents in Observational Studies

Impact of Completeness of Revascularization on Long-Term Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus

Clinical and Economic Outcomes of Liberal Versus Selective Drug-Eluting Stent Use

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