Target Lesion Revascularization In Patients Research Articles

TCT-500 Long-term Outcomes and Predictor of Target Lesion Revascularization in Patients After Treatment With Paclitaxel Coated Balloon for Drug-Eluted Stent Restenosis

TCT-500 Long-term Outcomes and Predictor of Target Lesion Revascularization in Patients After Treatment With Paclitaxel Coated Balloon for Drug-Eluted Stent Restenosis

A Novel Strategy for Emergency Treatment of Coronary Perforations by Placing a Drug-Eluting Stent before Sealing off the Leakage with a Covered Stent to Improve Long-Term Outcomes in Patients with Coronary Artery Perforations.

We aimed to investigate the safety, feasibility, and long-term results of drug-eluting stent implantation before covered stents for treating coronary artery perforation (CAP). Between 2015 and 2020, 12,733 patients undergoing percutaneous coronary intervention (PCI) were retrospectively analyzed. The primary endpoint was 1-year target lesion revascularization (TLR), whereas secondary endpoints included the rate of major adverse cardiac and cerebrovascular events (MACCE) and all-cause death at 1 year. A total of 159 patients with CAP were identified during the study period, of whom 47.2% (n = 75) were treated with a covered stent (CS group) because of complex and/or severe CAP and 84 (52.8%) without (non-CS group). In the majority of patients, emergency drug-eluting stent placement before covered stent implantation was feasible (n = 69, 82%). There were no significant differences among patients treated with or without a covered stent in terms of primary or secondary clinical endpoints: a similar rate of TLR (18.67% vs. 21.43%, p = 0.6646), MACCE (25.33% vs. 22.62%, p = 0.6887), and 1-year mortality (12.00% vs. 11.90%, p = 0.9853) were identified comparing cases with covered stent implantation and without. In conclusion, our study implicates that the use of covered stents for sealing coronary perforation might not impact the 1-year clinical outcome if used properly. Moreover, the emergent use of drug-eluting stents before covered stent implantation in CAP is a safe and effective method to avoid target lesion revascularization in patients treated with covered stents.

Impact of Eruptive vs Noneruptive Calcified Nodule Morphology on Acute and Long-Term Outcomes After Stenting

BackgroundWhether an eruptive or noneruptive target lesion calcified nodule (CN) portends worse acute and long-term clinical outcomes after stenting has not been established. ObjectivesThe authors sought to compare acute and long-term clinical outcomes in eruptive CN vs noneruptive CN morphology. MethodsUsing optical coherence tomography, an eruptive CN was defined as an accumulation of small calcium fragments protruding and disrupting the overlying fibrous cap, typically with small amount of thrombus. A noneruptive CN was defined as an accumulation of small calcium fragments with a smooth intact fibrous cap without an overlying thrombus. The primary endpoint was target lesion failure (TLF) including cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization in patients with ≥6-month follow-up. ResultsAmong 3,231 patients with evaluable pre- and postintervention OCT, 236 patients had lesions with CNs (7.3%). After eliminating 4 secondary lesions and 6 patients without ≥6-month follow-up, 126 (54.8%) lesions with eruptive CNs and 104 (45.2%) lesions with noneruptive CNs formed the current report. Compared with noneruptive CNs, eruptive CNs were independently associated with greater stent expansion (89.2% ± 18.7% vs. 81.5% ± 18.9%; P = 0.003) after adjusting for morphologic and procedural factors. At 2 years, eruptive CNs trended toward more TLF compared with noneruptive CNs (Kaplan-Meier estimates, 19.8% vs 12.5%; P = 0.11) and significantly more target lesion revascularization (18.3% vs 9.6%; P = 0.04). In the adjusted model, eruptive CNs were independently associated with 2-year TLF (HR: 2.07; 95% CI: 1.01-4.50; P = 0.048). ConclusionsCompared with noneruptive CN morphology, lesions with an eruptive CN appearance on optical coherence tomography had a worse poststent long-term clinical outcome despite better acute stent expansion.

Abstract 15463: Association of Coronary Plaque Morphology With Inflammatory Biomarkers and Target Lesion Revascularization in Patients With Stable Angina Pectoris

Background: In many countries, coronary artery disease (CAD) is one of the most common causes of death, and stable angina pectoris (SAP) is the most common initial symptomatic presentation. Despite the contemporary evolution of percutaneous coronary intervention (PCI) using drug-eluting stenting and a drug-coated balloon, restenosis and repeat revascularization still remain major concerns and are limiting the efficacy of PCI in patients with SAP . The characteristics of high-risk coronary atherosclerosis evaluated by optical coherence tomography (OCT) were suggested to have a prognostic role. Inflammatory biomarkers may be related to coronary artery disease severity. Accordingly, this study aimed to investigate the association of high-risk coronary plaque morphologies detected by OCT with circulating inflammatory biomarkers and adverse cardiovascular events. Methods: We prospectively analyzed the data of 30 consecutive patients with stable angina pectoris (SAP) who underwent percutaneous coronary intervention (PCI) using optical coherence tomography (OCT) between April 2020 and November 2020 in our university hospital. Inflammatory biomarker measurement and an OCT analysis focused on high-risk coronary plaque features were performed. Based on the coronary plaque risk score (CPRS), patients were defined as having a low CPRS (CPRS ≤3) or high CPRS (CPRS ≥4). The primary outcome was target lesion revascularization (TLR). Results: TLR occurred in 6 patients (20%) within 15 months after PCI. A high CPRS assessed by OCT was directly correlated to TLR (P=0.029). In a logistic regression analysis, the CPRS was associated with TLR (odds ratio, 10.0; 95% confidence interval, 1.34-74.5). Among inflammatory biomarkers, MCP-1 was significantly correlated with the CPRS (P=0.020). Conclusions: In patients with SAP, the CPRS may be a potential surrogate index for predicting TLR. MCP-1 might be useful for detecting high-risk coronary atherosclerosis.

Predictors of scaffold failure and impact of optimized scaffold implantation technique on outcome: Results from the German-Austrian ABSORB RegIstRy.

We aimed to investigate predictors of scaffold failure and the potential impact of an optimized scaffold implantation technique by means of a learning curve on long-term clinical outcome after bioresorbable scaffold (BRS) implantation and to evaluate predictors of scaffold failure. A total of 3326 patients were included in this prospective, observational, multi-center study (ClinicalTrials.gov NCT02066623) of consecutive patients undergoing BRS implantation between November 2013 and January 2016. The 3144 patients completed follow-up after 24 months, 3265 patients were eligible for time-to-event-analysis. Clinical endpoints were major adverse cardiac events-a composite endpoint of death, target vessel revascularization and myocardial infarction, and scaffold thrombosis (ScT). Patients were grouped according to treatment before or since 2015. During follow-up MACE rate improved from 2.52% after 30 days, 5.45% after 6 months and 12.67% after 24 months to 1.52%, 3.44%, and 10.52%, respectively. A total of 75 ScT occurred. In multiple regression analysis, treatment of bifurcations, long lesions, and procedures performed earlier than 2014 were identified as predictors for the occurrence of ScT. Treatment of bifurcation lesions is the strongest predictor of ScT following BRS implantation. A significantly lower incidence of ScT and 24-month target lesion revascularization in patients recruited after 2014 into our observational registry suggests the influence of a learning curve.

TCT-730 Five-year risk of target lesion revascularization in patients with and without an acute coronary syndrome treated with drug-eluting stents: a pooled analysis of individual participant data from three randomized SORT OUT trials

TCT-730 Five-year risk of target lesion revascularization in patients with and without an acute coronary syndrome treated with drug-eluting stents: a pooled analysis of individual participant data from three randomized SORT OUT trials

SYNTAX Score and Pre- and Poststent Optical Coherence Tomography Findings in the Left Anterior Descending Coronary Artery in Patients With Stable Angina Pectoris

SYNTAX score (SS) has been reported to be an independent predictor of future cardiac events including target lesion revascularization. The aim of this study was to assess the relation between SS and plaque characteristics and poststent vascular response using optical coherence tomography in coronary artery tree and left anterior descending artery (LAD) in patients with stable angina. A total of 179 lesions among 165 patients, including 100 lesions in LAD, were analyzed. Patients were stratified into tertiles. In pre-percutaneous coronary intervention analysis of whole coronary tree and LAD, lesions of the third tertile had the highest prevalence of lipid-rich plaque. Compared with the first tertile, the third tertile had greater lipid index, thinner fibrous cap, and higher prevalence of thin-cap fibroatheroma. In poststent optical coherence tomography, the incidence of stent edge dissection and irregular protrusion was higher in the third tertile compared with the first tertile in coronary tree analysis. In LAD analysis, the prevalence of irregular protrusion was the highest in the third tertile. In conclusion, high SS may reflect higher plaque vulnerability. Stent edge dissection and irregular protrusion were more frequent in patients with higher SS, indicating poor vascular response to stenting. Our results may explain higher cardiac event rate and target lesion revascularization in patients with higher SS.

Effect of Intravascular Ultrasound-Guided vs Angiography-Guided Everolimus-Eluting Stent Implantation: The IVUS-XPL Randomized Clinical Trial.

Use of intravascular ultrasound (IVUS) promotes better clinical outcomes for coronary intervention in complex coronary lesions. However, randomized data demonstrating the clinical usefulness of IVUS are limited for lesions treated with drug-eluting stents. To determine whether the long-term clinical outcomes with IVUS-guided drug-eluting stent implantation are superior to those with angiography-guided implantation in patients with long coronary lesions. The Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions (IVUS-XPL) randomized, multicenter trial was conducted in 1400 patients with long coronary lesions (implanted stent ≥28 mm in length) between October 2010 and July 2014 at 20 centers in Korea. Patients were randomly assigned to receive IVUS-guided (n = 700) or angiography-guided (n = 700) everolimus-eluting stent implantation. Primary outcome measure was the composite of major adverse cardiac events, including cardiac death, target lesion-related myocardial infarction, or ischemia-driven target lesion revascularization at 1 year, analyzed by intention-to-treat. One-year follow-up was complete in 1323 patients (94.5%). Major adverse cardiac events at 1 year occurred in 19 patients (2.9%) undergoing IVUS-guided and in 39 patients (5.8%) undergoing angiography-guided stent implantation (absolute difference, -2.97% [95% CI, -5.14% to -0.79%]) (hazard ratio [HR], 0.48 [95% CI, 0.28 to 0.83], P = .007). The difference was driven by a lower risk of ischemia-driven target lesion revascularization in patients undergoing IVUS-guided (17 [2.5%]) compared with angiography-guided (33 [5.0%]) stent implantation (HR, 0.51 [95% CI, 0.28 to 0.91], P = .02). Cardiac death and target lesion-related myocardial infarction were not significantly different between the 2 groups. For cardiac death, there were 3 patients (0.4%) in the IVUS-guided group and 5 patients (0.7%) in the angiography-guided group (HR, 0.60 [95% CI, 0.14 to 2.52], P = .48). Target lesion-related myocardial infarction occurred in 1 patient (0.1%) in the angiography-guided stent implantation group (P = .32). Among patients requiring long coronary stent implantation, the use of IVUS-guided everolimus-eluting stent implantation, compared with angiography-guided stent implantation, resulted in a significantly lower rate of the composite of major adverse cardiac events at 1 year. These differences were primarily due to lower risk of target lesion revascularization. clinicaltrials.gov Identifier: NCT01308281.

The Role of Vascular Imaging in Guiding Routine Percutaneous Coronary Interventions: A Meta-Analysis of Bare Metal Stent and Drug-Eluting Stent Trials.

The routine use of vascular imaging including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) in guiding percutaneous coronary interventions (PCI) is still controversial especially when using drug-eluting stents. A meta-analysis of trials using bare metal stents was previously published. We conducted a meta-analysis of available published trials that compared imaging-guided PCI and angiography-guided PCI in patients undergoing routine PCI only. Trials that enrolled patients with acute coronary syndrome were excluded to decrease heterogeneity. We aimed to study both drug-eluting stents (DES) as well as bare metal stents (BMS). We identified seven randomized controlled trials on IVUS-guided bare metal stents. We also identified three randomized controlled trials on IVUS-guided drug-eluting stents. To improve the power of the drug-eluting stent data, we identified, and included, nine registries that compared IVUS-guided PCI to angiography-guided PCI in the drug-eluting stent era. Nonrandomized registries that included BMS only were excluded as there are multiple previous meta-analyses that studied these patients. Finally, we identified one registry that compared OCT-guided PCI to angiography-guided PCI using either a BMS or a DES. A total of 14,197 patients were studied overall. The meta-analysis was conducted using a random effect model. Imaging guidance was associated with a significantly larger postintervention minimal luminal diameter (SMD: 0.289. 95% CI: 0.213-0.365. P < 0.01). Imaging-guided stenting was associated with a significant decrease in the major adverse cardiac events (MACE) in the DES patients (odds ratio: 0.810. 95% CI: 0.719-0.912. P < 0.01) and combined DES and BMS patients (odds ratio: 0.782. 95% CI: 0.686-0.890. P < 0.01). Imaging guidance was associated with significantly lower events of death from all causes in DES patients (odds ratio: 0.654. 95% CI: 0.468-0.916. P < 0.01) and in the combined DES and BMS patients (odds ratio: 0.727. 95% CI: 0.540-0.980. P < 0.01). The risk of myocardial infarction (MI) was significantly lower with imaging guidance in both, DES patients (odds ratio: 0.551. 95% CI: 0.363-0.837. P < 0.01) and combined DES and BMS patients (odds ratio: 0.589. 95% CI: 0.425-0.816. P < 0.01). This may, in part, be explained by the significantly lower risk of stent thrombosis in imaging-guided DES patients (odds ratio: 0.651. 95% CI: 0.499-0.850. P < 0.01) and combined DES and BMS patients (odds ratio: 0.665. 95% CI: 0.513-0.862. P < 0.01). Patients who received a DES showed no difference between imaging guidance and angiography guidance in repeated target lesion revascularization, while the analysis of BMS alone and the DES and BMS combined showed significant superiority of the imaging-guided PCI group. Imaging-guided PCI significantly lowered the risk of death, MI, stent thrombosis, and the combined MACE in DES-implanted patients and all stented patients (DES or BMS). However, imaging guidance had no significant effect on repeated target vessel or target lesion revascularization in patients who received DES, likely due to the effect of the drug in the stent.

Long-term effect of second-generation drug-eluting stents for coronary artery disease, everolimus-eluting versus zotarolimus-eluting stents: a meta-analysis.

Compared with the zotarolimus-eluting stent (ZES), the everolimus-eluting stent (EES) has reduced the risk of stent restenosis and thrombosis as found in a number of randomized-controlled trials (RCTs). However, the benefits have been variable. We evaluate the long-term effect of EES and ZES on the risk of stent thrombosis and target lesion revascularization in patients receiving PCI. We identified RCTs by a systematic search of MEDLINE, EMBASE, and Cochrane Database. Five RCTs (9853 patients) were included. Overall, EES significantly reduced the risk of target lesion revascularization [odds ratio (OR), 0.77; 95% confidence interval (CI), 0.62-0.95; P=0.01] compared with ZES therapy. However, there was no difference in the risk of target vessel revascularization (OR, 0.93; 95% CI, 0.78-1.10; P=0.38) and definite/probable stent thrombosis (OR, 0.83; 95% CI, 0.56-1.25; P=0.37) between the two groups. Furthermore, the risk of mortality (OR, 1.04; 95% CI, 0.84-1.27; P=0.73), myocardial infarction (OR, 0.95; 95% CI, 0.74-1.23; P=0.70), and major adverse cardiac event (OR, 0.96; 95% CI, 0.84-1.10; P=0.53) was similar between the two groups. The new-generation Resolute-ZES and EES have a similar long-term safety and efficacy profile.

Rational use of rotational atherectomy in calcified lesions in the drug-eluting stent era: Review of the evidence and current practice.

Percutaneous coronary interventions of calcified coronary lesions are associated with worse clinical outcomes compared with noncalcified lesions and are still considered a technical challenge for interventional cardiologists. Rotational atherectomy (RA) can effectively optimize lesion preparation through plaque modification of heavily calcified coronary lesions. However, in conventional balloon angioplasty and bare metal stent eras, the use of RA was not associated with a significant improvement in restenosis and target lesion revascularization in patients with calcified lesions. Drug-eluting stents (DES) dramatically reduced the rates of restenosis and major adverse cardiac events. In the DES era, the need for RA is therefore questionable. Recently, some studies have reported clinical outcomes of patients with calcified lesions treated with DES and RA. In this article, we aim to critically review results from these randomized and observational clinical studies assessing the use of RA in the DES era.

TCT-262 Comparison of Target Lesion Revascularization in Patients with Renal Insufficiency after Sirolimus-eluting Stent and Everolimus-eluting Stent Implantation: Three-year Outcomes from Single-center Retrospective Study

TCT-262 Comparison of Target Lesion Revascularization in Patients with Renal Insufficiency after Sirolimus-eluting Stent and Everolimus-eluting Stent Implantation: Three-year Outcomes from Single-center Retrospective Study

OP-066 The Factors Affecting Stent Restenosis and Target Lesion Revascularization

Stenting is the most widely performed procedure for the treatment of coronary arter disease.Many studies have investigated the superiority of one another about drug-eluting and bare metal stents. Many studies do not represent real conditions and clinic outcomes that they have been applied for the selective criteria. We tried to reflect real clinical outcomes in our study,reviewing all patients with stent implantation that followed over six months from June 2007 to August 2011 in our clinic.Our aim is to evaluate the frequency of stent restenosis and target lesion revascularization in patients with various brands of stents in all indications in our clinic and to identify the effect of clinical, angiographic,and procedure-related variables about this frequency, according to the type of stent.

Paclitaxel-Coated Versus Uncoated Balloon Angioplasty Reduces Target Lesion Revascularization in Patients With Femoropopliteal Arterial Disease

In disease of the femoropopliteal artery, paclitaxel-coated balloon (PCB) therapy improved angiographic outcomes as compared with uncoated balloon (UCB) angioplasty. Nevertheless, it remains uncertain whether PCB may reduce the need for reintervention. We searched Medline, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), scientific session abstracts, and relevant web sites for trials of PCB versus UCB angioplasty. Key words were: "superficial femoral artery," "popliteal artery," "angioplasty," "drug-eluting balloon," "paclitaxel-eluting balloon," and "randomized trial." Inclusion criteria were: (1) randomized design; (2) intention-to-treat analysis; and (3) ≥6-month follow-up. Exclusion criteria were: (1) vessel treated other than femoropopliteal artery; (2) device used other than PCB/UCB; and (3) irretrievable or duplicated data. No restrictions (language, publication date, or status) were applied. The primary end point was target lesion revascularization. Secondary end points were: angiographic binary restenosis and late lumen loss and all-cause mortality. A total of 381 patients enrolled in 4 randomized trials were included (PCB, n=186 versus UCB, n=195). Median follow-up was 10.3 months. Angioplasty with PCB versus UCB reduces target lesion revascularization (12.2% versus 27.7%; OR, 0.22; 95% CI, 0.13-0.38; P<0.00001), angiographic restenosis (18.7% versus 45.5%; OR, 0.26; 95% CI, 0.14-0.48; P<0.0001), and late lumen loss (range, -0.05 to 0.50 mm versus 0.61-1.7 mm; weighted mean difference, -0.75 mm; 95% CI, -1.06 to -0.45; P<0.00001). No mortality difference was observed for PCB versus UCB (2.1% versus 3.2%; OR, 0.99; 95% CI, 0.39-2.49; P=0.98). In femoropopliteal arterial disease, PCB therapy is associated with superior antirestenotic efficacy as compared with UCB angioplasty with no evidence of a differential safety profile.

The impact of severe distal left main disease on target lesion revascularization in patients with trifurcating coronary artery disease receiving the paclitaxel drug-eluting stent

The presence of severe left main (LM) disease has been shown to adversely influence the outcome of patients undergoing percutaneous treatment of bifurcating LM disease. LM trifurcating coronary artery disease (LMTCAD) is even more complex and challenging to treat. The present article reports on the immediate and midterm outcomes of patients with severe LM disease treated with the paclitaxel drug-eluting stent for LMTCAD. Consecutive patients (n=52) who underwent LM trifurcating stenting with the paclitaxel drug-eluting stent at the Genesis Medical Center (Iowa, USA) over a two-year period were divided into two groups: type A (with severe [50% or greater] LM involvement including trifurcating branches) and type B (with no LM involvement but involving the trifurcating branches). Demographic, clinical, procedural and midterm clinical outcomes were reviewed. Angiograms were analyzed by an operator who was blinded to patient histories. The primary end point of the study was target lesion revascularization (TLR) on follow-up. Descriptive and univariate analyses were performed, and survival curves were plotted to compare the two groups. Demographic and clinical variables were identical in both groups. Type A lesions required significantly more stents to treat than type B lesions (4.13±1.78 versus 2.33±1.22; P=0.001). The techniques to treat both lesions were considerably different, with more V stenting in type B and more Y stenting in type A. The TLR rate was 64.3% in type A versus 18.2% in type B (P=0.005). On follow-up, one patient with type B disease had sudden death, possibly related to stent thrombosis. Severe LM disease has a significant adverse impact on TLR in patients with LMTCAD. Given the high TLR rate, bypass surgery needs to be considered as first-line therapy in patients with type A trifurcating coronary artery disease.

Predictor of subsequent target lesion revascularization in patients with drug-eluting stent restenosis undergoing percutaneous coronary intervention

The best way to treat in-stent restenosis (ISR) after drug-eluting stent (DES) implantation remains unclear. The aim of this study was to evaluate angiographic restenosis and target lesion revascularization (TLR) at 8 months after intervention in patients with DES-ISR, and to identify predictive factors of subsequent TLR after treatment of DES-ISR. A total of 100 patients with 105 lesions underwent subsequent intervention for DES-ISR between April 2004 and January 2009. At baseline, focal and diffuse ISR were observed in 76.2% and 23.8%. DES-ISR was treated by five modalities: sirolimus-eluting stent (n=42); paclitaxel-eluting stent (n=24); balloon angioplasty (n=23); cutting balloon angioplasty (n=14); and bare-metal stent (n=2). Angiographic follow-up data were available for 95 lesions (91%). The rates of angiographic restenosis and TLR were 37.9% and 33.3%. Late loss of sirolimus-eluting stent, paclitaxel-eluting stent, cutting balloon, and balloon angioplasty were 0.50 mm, 0.49 mm, 0.93 mm, and 1.10 mm. By multivariate analysis, totally occluded ISR (OR 15.43, p=0.0005), diabetes mellitus (OR 3.45, p=0.02), and re-stenting with DES (OR 0.14, p=0.0002) were identified as independent predictors of TLR. The restenosis rate was significant in this cohort of patients with DES-ISR. Angiographic pattern of DES-ISR and diabetes mellitus are the most important predictors of TLR, whereas re-stenting with DES is protective.

Smoking Interaction with Clopidogrel; Another Smoker's Paradox?

The American Heart Association estimates that one in five deaths from cardiovascular disease are directly linked to cigarette smoking. Individuals who smoke are two to six times more likely to develop coronary artery disease than nonsmokers. However, individuals who quit smoking will reduce their risk to levels equivalent to those of a nonsmoker within three years. Refer to the page 119-124 Exposure to cigarette smoke is an established risk factor for coronary heart disease in both Western and Asian countries. The multivariate relative risk of coronary heart disease mortality for current smokers was 1.8-3.7 compared to nonsmokers.1) Poor prognosis in smokers results from: 1) induction of hypercoagulability due to increased platelet activation, dyslipidemia, and endothelial dysfunction; 2) increased catecholamine release leading to increased heart rate, blood pressure, coronary vasoconstriction, and even arrhythmogenic effect; and 3) reduction in oxygen delivery due to increased carbon monoxide levels.2) The term of smoker's paradox has been coined by Barbash et al.3) who reported better outcomes among the smokers receiving thrombolytic therapy for acute myocardial infarction. Similarly, Cohen et al.4) reported that cigarette smoking was associated with a lower rate of subsequent target lesion revascularization in patients undergoing percutaneous coronary intervention (PCI). Hasdai et al.5) reported that current smokers during an index percutaneous intervention had fewer adverse events in the univariable analysis than the nonsmokers and former smokers. This improved can be explained in part by better covariables such as younger age or a more favorable clinical and angiographic profile. Therefore, this term may be misleading.6) Clopidogrel, an inhibitor of the platelet P2Y12 adenosine diphosphate receptor, improves prognosis in patients with acute coronary syndrome (ACS). However, there is significant response variability and a diminished clopidogrel response is associated with an increased risk of ischemic events.7) Smoking induces cytochrome P450 1A2 (CYP1A2), a hepatic enzyme involved in the metabolism of clopidogrel. Clopidogrel shows better inhibition of platelet aggregation in smokers than nonsmokers,8) and smokers are less likely to be hyporesponders than nonsmokers.9) In this issue of the Journal, Cho et al.10) investigated the association between smoking status and post-clopidogrel platelet reactivity in patients with acute myocardial infarction. Differences in the clinical situation and timing of the platelet test could explain the differences with the Bliden study.8) The decreases in CYP1A2 activity induced by smoking may also disappear after three days. The CHARISMA (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance) trial compared long-term clopidogrel 75 mg/day vs. placebo in patients at high risk for cardiovascular events, and clopidogrel significantly reduced mortality in smokers but not in former or never-smokers.11) In addition to CYP1A2 activation by smoking, smokers may simply be a higher-risk group because of enhanced platelet activity and therefore benefit more from antithrombotic intervention. The Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis In Myocardial Infarction 28 (CLARITY-TIMI 28) trial compared the effect of clopidogrel on angiographic and clinical outcomes in 3,429 ST elevation myocardial infarction patients by smoking intensity: not current smokers (n=1,732), and smokers of 1 to 9 (n=206), 10 to 19 (n=354), 20 to 29 (n=715), and ≥30 cigarettes/day (n=422). Clopidogrel reduced the primary end point of a closed infarct-related artery or death/myocardial infarction, particularly among those who smoked ≥10 cigarettes/day.12) The CURRENT-OASIS 7 (Clopidogrel Optimal Loading Dose Usage to Reduce Recurrent Events/Optimal Antiplatelet Strategy for Interventions) trial, which tested high-dose vs. usual-dose clopidogrel in ACS patients undergoing PCI, showed that smokers (vs. nonsmokers) had significant benefit with the higher clopidogrel dose. Smoking increases the risk for cardiovascular events and mortality in patients with established cardiovascular disease, but clopidogrel treatment may be more effective in smokers. Therefore, the interaction of smoking with acute myocardial infarction deserves further study in more patients using designs that show fewer time limitations.

Meta-Analysis of Five Randomized Clinical Trials Comparing Sirolimus- Versus Paclitaxel-Eluting Stents in Patients With Diabetes Mellitus

Recent data on drug-eluting stents have shown improved clinical outcomes in patients with diabetes mellitus. However, the relative efficacy and safety of sirolimus-eluting stents (SES) compared with paclitaxel-eluting stents (PES) remains controversial. Therefore, a meta-analysis of randomized trials was performed to compare SES with PES exclusively in patients with diabetes. The published research was scanned by formal searches of electronic databases (PubMed, EMBASE and the Cochrane Central Register of Controlled Trials) from January 2001 to April 2009. All randomized trials involving head-to-head comparison of SES versus PES in patients with diabetes were examined for analysis. A total of 5 randomized trials were included in the present meta-analysis, involving 1,173 patients (594 in the SES group, 579 in the PES group). SES were significantly more effective in the reduction of target lesion revascularization (5.1% vs 11.4%, odds ratio [OR] 0.41, 95% confidence interval [CI] 0.26 to 0.64, p <0.001) and angiographic binary (> or =50%) restenosis (5.6% vs 16.4%, OR 0.30, 95% CI 0.19 to 0.48, p <0.001) compared to PES. In contrast, the differences between SES and PES were not statistically significant with respect to cardiac death (2.2% vs 2.9%, OR 0.71, 95% CI 0.34 to 1.47, p = 0.35), myocardial infarction (1.5% vs 2.6%, OR 0.58, 95% CI 0.26 to 1.31, p = 0.19), and stent thrombosis (0.6% vs 1.2%, OR 0.57, 95% CI 0.18 to 0.84, p = 0.35). In conclusion, SES are superior to PES in reducing the incidences of restenosis and target lesion revascularization in patients with diabetes, with nonsignificant differences in terms of cardiac death, myocardial infarction, and stent thrombosis.

Long-Term Safety and Effectiveness of Unprotected Left Main Coronary Stenting With Drug-Eluting Stents Compared With Bare-Metal Stents

Limited information is available on long-term outcomes for patients with unprotected left main coronary artery disease who received drug-eluting stents (DES). In the multicenter registry evaluating outcomes among patients with unprotected left main coronary artery stenosis undergoing stenting with either bare metal stents (BMS) or DES, 1217 consecutive patients were divided into 2 groups: 353 who received only BMS and 864 who received at least 1 DES. The 3-year outcomes were compared by use of the adjustment of inverse-probability-of-treatment-weighted method. Patients receiving DES were older and had a higher prevalence of diabetes mellitus, hypertension, hyperlipidemia, and multivessel disease. In the overall population, with the use of DES, the 3-year adjusted risk of death (8.0% versus 9.5%; hazard ratio, 0.71; 95% confidence interval, 0.36 to 1.40; P=0.976) or death or myocardial infarction (14.3% versus 14.9%; hazard ratio, 0.83; 95% confidence interval, 0.49 to 1.40; P=0.479) was similar compared with BMS. However, the risk of target lesion revascularization was significantly lower with the use of DES than BMS (5.4% versus 12.1%; hazard ratio, 0.40; 95% confidence interval, 0.22 to 0.73; P=0.003). When patients were classified according to lesion location, DES was still associated with lower risk of target lesion revascularization in patients with bifurcation (6.9% versus 16.3%; hazard ratio, 0.38; 95% confidence interval, 0.18 to 0.78; P=0.009) or nonbifurcation (3.4% versus 10.3%; hazard ratio, 0.39; 95% confidence interval, 0.17 to 0.88; P=0.024) lesions with a comparable risk of death or myocardial infarction. Compared with BMS, DES was associated with a reduction in the need for repeat revascularization without increasing the risk of death or myocardial infarction for patients with unprotected left main coronary artery stenosis.

AS-42: A Randomized Comparison of Triple Antiplatelet Therapy with Dual Antiplatelet Therapy in Patients at High-Risk of Restenosis after Drug-Eluting Stent Implantation: 2-year Clinical Outcomes of DECLARE-DIABETES and LONG Trials

Although cilostazol has reduced 6-month restenosis and 9-month target lesion revascularization in patients at high risk of restenosis after DES implantation, it is not known whether this effect is durable at 2 years after DES implantation.