title: Clinical presentation and outcomes of coronary in-stent restenosis across 3-stent generations.
abstract: BACKGROUND
  Clinical presentation of bare metal stent in-stent restenosis (ISR) in patients undergoing target lesion revascularization is well characterized and negatively affects on outcomes, whereas the presentation and outcomes of first- and second-generation drug-eluting stents (DESs) remains under-reported.
  
  
  RESULTS
  The study included 909 patients (1077 ISR lesions) distributed as follows: bare metal stent (n=388), first-generation DES (n=425), and second-generation DES (n=96), categorized into acute coronary syndrome (ACS) or non-ACS presentation mode at the time of first target lesion revascularization. ACS was further classified as myocardial infarction (MI) and unstable angina. For bare metal stent, first-generation DES and second-generation DES, ACS was the clinical presentation in 67.8%, 71.0%, and 66.7% of patients, respectively (P=0.470), whereas MI occurred in 10.6%, 10.1%, and 5.2% of patients, respectively (P=0.273). The correlates for MI as ISR presentation were current smokers (odds ratio, 3.02; 95% confidence interval [CI], 1.78-5.13; P<0.001), and chronic renal failure (odds ratio, 2.73; 95% CI, 1.60-4.70; P<0.001), with a protective trend for the second-generation DES ISR (odds ratio, 0.35; 95% CI, 0.12-1.03; P=0.060). ACS presentations had an independent effect on major adverse cardiac events (death, MI, and re-target lesion revascularization) at 6 months (MI versus non-ACS: adjusted hazard ratio, 4.06; 95% CI, 1.84-8.94; P<0.001; unstable angina versus non-ACS: adjusted hazard ratio, 1.98; 95% CI, 1.01-3.87; P=0.046).
  
  
  CONCLUSIONS
  ISR clinical presentation is similar irrespective of stent type. MI as ISR presentation seems to be associated with patient and not device-related factors. ACS as ISR presentation has an independent effect on major adverse cardiac events, suggesting that ISR remains a hazard and should be minimized.
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Marco A
authors.initials: MA
authors.lastname: Magalhaes
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Sa'ar
authors.initials: S
authors.lastname: Minha
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Fang
authors.initials: F
authors.lastname: Chen
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Torguson
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Al Fazir
authors.initials: AF
authors.lastname: Omar
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Loh
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Ricardo O
authors.initials: RO
authors.lastname: Escarcega
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Lipinski
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Nevin C
authors.initials: NC
authors.lastname: Baker
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Hironori
authors.initials: H
authors.lastname: Kitabata
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Hideaki
authors.initials: H
authors.lastname: Ota
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: William O
authors.initials: WO
authors.lastname: Suddath
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Lowell F
authors.initials: LF
authors.lastname: Satler
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC.
authors.forename: Augusto D
authors.initials: AD
authors.lastname: Pichard
authors.affiliation: From the Division of Cardiology, Department of Internal Medicine, MedStar Washington Hospital Center, DC. ron.waksman@medstar.net.
authors.forename: Ron
authors.initials: R
authors.lastname: Waksman
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D000368:Aged; D000789:Angina, Unstable / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016009:Chi-Square Distribution; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D023921:Coronary Stenosis / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000517:prevention & control; D054855:Drug-Eluting Stents; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008670:Metals; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects* / Q000295:instrumentation* / Q000401:mortality; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D065840:Protective Factors; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D008670:Metals
keywords: drug-eluting stents; restenosis; stents