Drug-eluting stents for ST[corrected]-elevation acute myocardial infarction: do we need randomized trials?
Since their introduction, drug-eluting stents have rapidly altered modern medicine's approach to coronary artery disease. Before the development of drug-eluting stents, standard bare-metal stents were plagued by in-stent restenosis, requiring repeat revascularization in as many as 15-20% of patients during the first 6-12 months following implantation [1]. The currently approved drug-eluting stents have dramatically reduced this complication by using a polymer-impregnated coating that elutes either paclitaxel or sirolimus to inhibit smooth muscle proliferation. The pivotal TAXUS-IV [2] and SIRIUS [3] trials compared drug-eluting stents with standard bare-metal stents and found rates of target vessel revascularization ranging from 3 to 4.1% in stable coronary artery disease patients - far lower than that had been seen previously with conventional standard bare-metal stents. After their approval in April 2003, drug-eluting stents use in clinical practice expanded rapidly. Within 9 months of their introduction, drug-eluting stents comprised 35% of all stent implantations in the United States [4]. In the last year at our own institution, drug-eluting stents comprised over 85% of all stents implanted. Despite their extensive use, data regarding the efficacy and safety of drug-eluting stents in certain clinical scenarios are limited. To date, the only published data supporting drug-eluting stents in ST[corrected]-elevation acute myocardial infarction come from the retrospective Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital registry [5] and the randomized, controlled single high-dose bolus tirofiban and sirolimus-eluting stent vs. abciximab and bare-metal stent in myocardial infarction study [6]. In this chapter, we discuss the theoretical risks and benefits of drug-eluting stents for ST elevation acute myocardial infarction, the available data regarding their use, and the areas in which future studies are needed.
Ryan
Jason
J
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. dpinto@caregroup.harvard.edu
Cohen
David J
DJ
Pinto
Duane S
DS
D020099:Coated Materials, Biocompatible / Q000009:adverse effects*; D023921:Coronary Stenosis / Q000601:surgery; D003328:Coronary Thrombosis / Q000150:complications*; D006801:Humans; D009203:Myocardial Infarction / Q000209:etiology*; D009204:Myocardial Revascularization / Q000295:instrumentation*; D011475:Prosthesis Failure; D012307:Risk Factors; D015607:Stents / Q000009:adverse effects*
D020099:Coated Materials, Biocompatible