Advertisement






Click here for more guidelines.
CME Topic Collections Past Issues Search Current Issue Home
     

J Am Coll Cardiol, 2008; 51:1844-1853, doi:10.1016/j.jacc.2008.01.042
© 2008 by the American College of Cardiology Foundation
This Article
Right arrow Figures Only
Right arrow Full Text
Right arrow Full Text (PDF)
Right arrow View Online Appendix
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in Web of Science
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Web of Science (6)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Garg, P.
Right arrow Articles by Mauri, L.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Garg, P.
Right arrow Articles by Mauri, L.
Related Collections
Right arrowRelated Articles

CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Balancing the Risks of Restenosis and Stent Thrombosis in Bare-Metal Versus Drug-Eluting Stents

Results of a Decision Analytic Model

Pallav Garg, MBBS, MSc*,§, David J. Cohen, MD, MSc{ddagger},*, Thomas Gaziano, MD, MSc{dagger} and Laura Mauri, MD, MSc*,§

* Divisions of Cardiology and Clinical Biometrics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
{dagger} Division of Cardiology and Social Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
{ddagger} Saint Luke's Mid-America Heart Institute, University of Missouri–Kansas City, Kansas City, Missouri
§ Harvard Clinical Research Institute, Boston, Massachusetts.

Manuscript received September 18, 2007; revised manuscript received November 29, 2007, accepted January 6, 2008.

* Reprint requests and correspondence: Dr. David J. Cohen, Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, Missouri 64111. (Email: dcohen{at}saint-lukes.org).

Objectives: We sought to define what incremental risk of very late stent thrombosis (VLST) in drug-eluting stents (DES) would outweigh the restenosis benefit.

Background: Although there are robust data on the restenosis benefit of DES versus bare-metal stents (BMS), the incremental risk of stent thrombosis, a rare but serious complication of percutaneous coronary intervention (PCI), is not known with certainty.

Methods: We developed a decision analytic Markov model comparing DES versus BMS strategies for a contemporary PCI population. Procedure-related morbidity and mortality data from published reports were used to derive the model probabilities. Over a range of incremental risk and duration of risk of VLST, we identified the net benefit of DES versus BMS in terms of quality-adjusted life expectancy (QALE).

Results: Under an assumption of equal stent thrombosis rates beyond 1 year, the DES strategy was superior to BMS in terms of QALE (16.262 vs. 16.248 quality-adjusted life years [QALYs], difference = 0.014). Under the alternative assumption of an incremental risk difference of 0.13%/year, the net benefit was substantially reduced (difference = 0.001 QALYs). The threshold excess risk of very late DES thrombosis compared with BMS, above which BMS would be the preferred strategy, was 0.14%/year (over 4 years of follow-up). This threshold increased as the population risk of restenosis increased and decreased as the vulnerable time window lengthened.

Conclusions: A small absolute increase in DES thrombosis compared with BMS after 1 year (>0.14%/year) would result in BMS being the preferred strategy for the overall PCI population. Larger clinical trials with longer follow-up are needed to estimate the risk of late stent thrombosis with greater certainty for existing and new DES.

Abbreviations and Acronyms
  BMS = bare-metal stent(s)
  CABG = coronary artery bypass graft surgery
  DES = drug-eluting stent(s)
  PCI = percutaneous coronary intervention
  PTCA = percutaneous transluminal coronary angioplasty
  QALE = quality-adjusted life expectancy
  QALY = quality-adjusted life year
  TVR = target vessel revascularization
  VLST = very late stent thrombosis


Related Articles

Interpreting the Music of Drug-Eluting Stents: Halcyon Song or Albatross Dirge?
Daniel B. Mark
J. Am. Coll. Cardiol. 2008 51: 1854-1856. [Full Text] [PDF]

Inside This Issue of JACC
J. Am. Coll. Cardiol. 2008 51: A35-A36. [Full Text] [PDF]



This article has been cited by other articles:


Home page
J Am Coll Cardiol IntvHome page
A. J. Kirtane, R. Patel, C. O'Shaughnessy, P. Overlie, B. McLaurin, S. Solomon, L. Mauri, P. Fitzgerald, J. J. Popma, D. E. Kandzari, et al.
Clinical and Angiographic Outcomes in Diabetics From the ENDEAVOR IV Trial: Randomized Comparison of Zotarolimus- and Paclitaxel-Eluting Stents in Patients With Coronary Artery Disease
J. Am. Coll. Cardiol. Intv., October 1, 2009; 2(10): 967 - 976.
[Abstract] [Full Text] [PDF]


Home page
J Am Coll CardiolHome page
L. Marcoff, Z. Zhang, W. Zhang, E. Ewen, C. Jurkovitz, P. Leguet, P. Kolm, and W. S. Weintraub
Cost effectiveness of enoxaparin in acute ST-segment elevation myocardial infarction: the ExTRACT-TIMI 25 (Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment-Thrombolysis In Myocardial Infarction 25) study.
J. Am. Coll. Cardiol., September 29, 2009; 54(14): 1271 - 1279.
[Abstract] [Full Text] [PDF]


Home page
CirculationHome page
A. J. Kirtane, A. Gupta, S. Iyengar, J. W. Moses, M. B. Leon, R. Applegate, B. Brodie, E. Hannan, K. Harjai, L. O. Jensen, et al.
Safety and Efficacy of Drug-Eluting and Bare Metal Stents: Comprehensive Meta-Analysis of Randomized Trials and Observational Studies
Circulation, June 30, 2009; 119(25): 3198 - 3206.
[Abstract] [Full Text] [PDF]


Home page
J Am Coll CardiolHome page
D. J. Cohen and M. R. Reynolds
Interpreting the results of cost-effectiveness studies.
J. Am. Coll. Cardiol., December 16, 2008; 52(25): 2119 - 2126.
[Abstract] [Full Text] [PDF]


Home page
JWatch GeneralHome page
Drug-Eluting vs. Bare-Metal Stents: Weighing a Lower Restenosis Rate Against Late Thrombosis
Journal Watch (General), July 31, 2008; 2008(731): 3 - 3.
[Full Text]


Home page
J Am Coll CardiolHome page
D. B. Mark
Interpreting the Music of Drug-Eluting Stents: Halcyon Song or Albatross Dirge?
J. Am. Coll. Cardiol., May 13, 2008; 51(19): 1854 - 1856.
[Full Text] [PDF]



 
  CME Topic Collections Past Issues Search Current Issue Home

Advertisement