What does this research mean for the field?

Q: What does this research mean for the field?

In elderly patients undergoing percutaneous coronary intervention, drug-eluting stents significantly reduce major adverse cardiovascular events, myocardial infarction, and repeat revascularization compared to bare-metal stents, without increasing the risk of stent thrombosis or bleeding complications. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

April 30, 2020Cardiology JournalOpen Access

Efficacy and safety of drug-eluting stents in elderly patients: A meta-analysis of randomized trials

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Why the study?

Current guidelines recommend newer generation drug-eluting stents over bare-metal stents in patients with ischemic heart disease, but age-specific recommendations in elderly patients are lacking.

Does the use of drug-eluting stents reduce major adverse cardiovascular events compared to bare-metal stents in elderly patients (>70 years) undergoing PCI?

Structured PICO

Does the use of drug-eluting stents reduce major adverse cardiovascular events compared to bare-metal stents in elderly patients (>70 years) undergoing PCI?

Population

5,042 elderly patients (> 70 years old) with coronary artery disease undergoing percutaneous coronary intervention (PCI) across 6 randomized controlled trials.

Intervention

Drug-eluting stents (DES) (n=2,579)

Comparator

Bare-metal stents (BMS) (n=2,463)

Outcome

Major adverse cardiovascular events (MACEs), defined as a composite of cardiac death, myocardial infarction, and repeat revascularization (including target lesion and target vessel revascularization) at longest available follow-up (≥ 12 months).composite

In elderly patients undergoing PCI, drug-eluting stents significantly reduce MACE, myocardial infarction, and repeat revascularization compared to bare-metal stents, without increasing bleeding or stent thrombosis risks.

Limitations

Considerable heterogeneity between studies
Different definitions of MACE in each study
Definition of elderly varies (defined as >70 years here)
Differences in DAPT duration according to DES or BMS use reported in only 1 of 6 trials
Two types of EES (durable vs bioabsorbable polymer) might affect results
Proportion of ACS patients could not be assessed in DAPT duration groups

Implication

Supports DES over BMS in elderly PCI patients; extends general-population RCT evidence to this high-risk group.

Abstract

BACKGROUND: Current guidelines recommend newer generation drug-eluting stents (DES) over bare-metal stents (BMS) in patients with ischemic heart disease. However, there is no age-specific recommendation in elderly patients. METHODS: Meta-analysis was performed of 6 randomized studies enrolling 5,042 elderly patients who underwent percutaneous coronary intervention (PCI) with stent implantation (DES, n = 2,579; BMS, n = 2,463). RESULTS: Combined data indicated a significant reduction in major adverse cardiovascular events (MACEs) with use of DES (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.44-0.71, p < 0.001). Moreover, use of DES was associated with a significantly lower incidence of myocardial infarction (OR 0.54, 95% CI 0.36-0.81, p = 0.003) and repeat revascularization (OR 0.44, 95% CI 0.31-0.62, p < 0.001), was compared to that with the use of BMS. Stent thrombosis and bleeding complication rates were not significantly different between groups. In a subgroup meta-analysis, short duration (1 or 6 months) dual antiplatelet therapy (DAPT) was associated with a significantly lower MACE rate (OR 0.49, 95% CI 0.34-0.80; p = 0.003) in elderly patients who underwent PCI with everolimuseluting stent implantation, compared with that using long duration DAPT. CONCLUSIONS: This meta-analysis provides clinically relevant evidence that DES rather than BMS should be selected for elderly patients.