title: Outcomes associated with drug-eluting and bare-metal stents: a collaborative network meta-analysis.
abstract: BACKGROUND
  Whether the two drug-eluting stents approved by the US Food and Drug Administration-a sirolimus-eluting stent and a paclitaxel-eluting stent-are associated with increased risks of death, myocardial infarction, or stent thrombosis compared with bare-metal stents is uncertain. Our aim was to compare the safety and effectiveness of these stents.
  
  
  METHODS
  We searched relevant sources from inception to March, 2007, and contacted investigators and manufacturers to identify randomised controlled trials in patients with coronary artery disease that compared drug-eluting with bare-metal stents, or that compared sirolimus-eluting stents head-to-head with paclitaxel-eluting stents. Safety outcomes included mortality, myocardial infarction, and definite stent thrombosis; the effectiveness outcome was target lesion revascularisation. We included 38 trials (18,023 patients) with a follow-up of up to 4 years. Trialists and manufacturers provided additional data on clinical outcomes for 29 trials. We did a network meta-analysis with a mixed-treatment comparison method to combine direct within-trial comparisons between stents with indirect evidence from other trials while maintaining randomisation.
  
  
  RESULTS
  Mortality was similar in the three groups: hazard ratios (HR) were 1.00 (95% credibility interval 0.82-1.25) for sirolimus-eluting versus bare-metal stents, 1.03 (0.84-1.22) for paclitaxel-eluting versus bare-metal stents, and 0.96 (0.83-1.24) for sirolimus-eluting versus paclitaxel-eluting stents. Sirolimus-eluting stents were associated with the lowest risk of myocardial infarction (HR 0.81, 95% credibility interval 0.66-0.97, p=0.030 vs bare-metal stents; 0.83, 0.71-1.00, p=0.045 vs paclitaxel-eluting stents). There were no significant differences in the risk of definite stent thrombosis (0 days to 4 years). However, the risk of late definite stent thrombosis (>30 days) was increased with paclitaxel-eluting stents (HR 2.11, 95% credibility interval 1.19-4.23, p=0.017 vs bare-metal stents; 1.85, 1.02-3.85, p=0.041 vs sirolimus-eluting stents). The reduction in target lesion revascularisation seen with drug-eluting stents compared with bare-metal stents was more pronounced with sirolimus-eluting stents than with paclitaxel-eluting stents (0.70, 0.56-0.84; p=0.0021).
  
  
  CONCLUSIONS
  The risks of mortality associated with drug-eluting and bare-metal stents are similar. Sirolimus-eluting stents seem to be clinically better than bare-metal and paclitaxel-eluting stents.
authors.affiliation: Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
authors.forename: Christoph
authors.initials: C
authors.lastname: Stettler
authors.forename: Simon
authors.initials: S
authors.lastname: Wandel
authors.forename: Sabin
authors.initials: S
authors.lastname: Allemann
authors.forename: Adnan
authors.initials: A
authors.lastname: Kastrati
authors.forename: Marie Claude
authors.initials: MC
authors.lastname: Morice
authors.forename: Albert
authors.initials: A
authors.lastname: Schömig
authors.forename: Matthias E
authors.initials: ME
authors.lastname: Pfisterer
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
authors.forename: Martin B
authors.initials: MB
authors.lastname: Leon
authors.forename: José Suarez
authors.initials: JS
authors.lastname: de Lezo
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Goy
authors.forename: Seung-Jung
authors.initials: SJ
authors.lastname: Park
authors.forename: Manel
authors.initials: M
authors.lastname: Sabaté
authors.forename: Maarten J
authors.initials: MJ
authors.lastname: Suttorp
authors.forename: Henning
authors.initials: H
authors.lastname: Kelbaek
authors.forename: Christian
authors.initials: C
authors.lastname: Spaulding
authors.forename: Maurizio
authors.initials: M
authors.lastname: Menichelli
authors.forename: Paul
authors.initials: P
authors.lastname: Vermeersch
authors.forename: Maurits T
authors.initials: MT
authors.lastname: Dirksen
authors.forename: Pavel
authors.initials: P
authors.lastname: Cervinka
authors.forename: Anna Sonia
authors.initials: AS
authors.lastname: Petronio
authors.forename: Alain J
authors.initials: AJ
authors.lastname: Nordmann
authors.forename: Peter
authors.initials: P
authors.lastname: Diem
authors.forename: Bernhard
authors.initials: B
authors.lastname: Meier
authors.forename: Marcel
authors.initials: M
authors.lastname: Zwahlen
authors.forename: Stephan
authors.initials: S
authors.lastname: Reichenbach
authors.forename: Sven
authors.initials: S
authors.lastname: Trelle
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
authors.forename: Peter
authors.initials: P
authors.lastname: Jüni
mesh_terms: D005260:Female; D006801:Humans; D008297:Male; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use; D003327:Coronary Disease / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D005500:Follow-Up Studies; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D017239:Paclitaxel / Q000008:administration & dosage / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D020123:Sirolimus / Q000008:administration & dosage / Q000627:therapeutic use; D015607:Stents / Q000009:adverse effects
chemical_list: D000900:Anti-Bacterial Agents; D017239:Paclitaxel; D020123:Sirolimus