title: Selective drug-eluting stent implantation for high-risk patients with acute ST-elevation myocardial infarction: rationale and safety.
abstract: BACKGROUND
  A selective policy of drug-eluting stent (DES) implantation in ST-elevation myocardial infarction (STEMI) patients at high risk of restenosis may maximize the benefit from restenosis reduction and minimize risk from late stent thrombosis (LaST).
  
  
  OBJECTIVE
  We sought to prospectively determine the safety of selective DES implantation for long lesions (>20 mm), small vessels (<2.5 mm) and diabetic patients in patients with STEMI using a prospective single-center registry.
  
  
  METHODS
  A total of 252 patients who underwent primary PCI between January 2005 and December 2006 were included: 126 consecutive patients receiving DES were compared with 126 age-, sex-, and vessel-matched controls with STEMI who received bare-metal stents. Composite major adverse cardiovascular events (MACE) (death, AMI, and target vessel revascularization) were used as the primary outcome measure.
  
  
  RESULTS
  Baseline clinical and angiographic characteristics and outcomes were similar between groups except for the prespecified diabetes, lesion length, and maximum stent diameter. Long-term outcomes at a median follow up of 34 ± 6 months showed significant reductions in reinfarction (2% vs. 11%, P = 0.03), target vessel revascularization (TVR) (10% vs. 24%, P = 0.02), and composite MACE (18% vs. 31%, P = 0.03) with DES, with no excess of death (9% vs. 7%, P = NS) or LaST (2% vs. 1%, P = NS). In a Cox multivariate model, clopidogrel cessation at long-term follow-up was the most powerful predictor of hierarchical MACE (HR: 5.165; 95%CI: 2.019-13.150, P = 0.001).
  
  
  CONCLUSIONS
  Selective DES implantation in patients with high-risk STEMI appears safe, and exposes fewer patients to the risk of LaST. A randomized comparison of selective versus routine DES use in patients with STEMI should be considered.
authors.affiliation: Monash Cardiovascular Research Centre, Clayton, Melbourne, Victoria, Australia. sprasad@bigpond.net.au
authors.forename: Sandhir B
authors.initials: SB
authors.lastname: Prasad
authors.forename: Thomas
authors.initials: T
authors.lastname: David
authors.forename: Yuvaraj
authors.initials: Y
authors.lastname: Malaiapan
authors.forename: James D
authors.initials: JD
authors.lastname: Cameron
authors.forename: Ian T
authors.initials: IT
authors.lastname: Meredith
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D017023:Coronary Angiography; D023903:Coronary Restenosis / Q000209:etiology; D054855:Drug-Eluting Stents; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D018579:Patient Selection; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011474:Prosthesis Design; D012008:Recurrence; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013927:Thrombosis / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome; D014739:Victoria
chemical_list: D010975:Platelet Aggregation Inhibitors