Transition from bare metal to drug eluting stenting in contemporary US practice: effect on incidence and predictors of clinically driven target lesion revascularization.
BACKGROUND
The performance of drug eluting stents (DES) and impact on every day practice in the USA, where complex, nonselective cases are the rule, remain unknown.


METHODS
The Brigham and Women's Hospital interventional experience in the bare metal stents (BMS) (6/2002 to 2/2003) and after abrupt and near universal adoption of DES (4/2003 to 9/2004) were compared. Demographic, procedural and in-hospital outcomes for all consecutive cases where investigated. Predictors and angiographic characteristics of patients returning for clinically driven target lesion revascularization (TLR) in both eras were analyzed.


RESULTS
Of 2,555 DES cases (3,061 lesions, 87.9% Cypher, 12.1% Taxus), 47 underwent TLR during follow-up (68 lesions, 2.2%). Of the 1,731 BMS cases (1,798 lesions), 162 underwent clinically indicated TLR (209 lesions, 11.6%), representing an 81% DES era TLR risk reduction. Multivariate predictors of TLR in the DES era: left main lesion (LM) (odds ratio (OR) 7.65, 95% confidence interval (CI) 3.33-17.53, P<0.01, treatment of restenosis (OR 5.96, CI 3.21-11.08, P<0.01), and diabetes (OR 1.68, CI 0.92-3.04, P=0.07). Predictors of restenosis in the BMS era included additional clinical, lesion, and stent characteristics, while LM lesion was absent. Angiographic patterns of stent restenosis differed in the DES (focal) and BMS (diffuse) era.


CONCLUSIONS
The transition from BMS to DES in the setting of a large USA hospital practice is safe and associated with significant reduction in clinically driven TLR. Treatment of specific lesions types (repeat restenosis, distal LM) and diabetic patients remain suboptimal and warrant further investigation.
Jonas
Michael
M
Cardiovascular Division (Cardiac Catheterization Laboratory), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. tmjonas@yahoo.com
Resnic
Frederic S
FS
Levin
Andrew D
AD
Arora
Nipun
N
Rogers
Campbell David
CD
D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation* / Q000706:statistics & numerical data; D001900:Boston / Q000453:epidemiology; D002317:Cardiovascular Agents / Q000008:administration & dosage*; D002318:Cardiovascular Diseases / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality; D017023:Coronary Angiography; D023903:Coronary Restenosis / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality; D048909:Diabetes Complications / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008670:Metals; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D016017:Odds Ratio; D011446:Prospective Studies; D011474:Prosthesis Design; D012042:Registries; D012107:Research Design; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome
D002317:Cardiovascular Agents; D008670:Metals