First-generation versus second-generation drug-eluting stents in current clinical practice: updated evidence from a comprehensive meta-analysis of randomised clinical trials comprising 31 379 patients

Abstract

BackgroundFirst-generation drug-eluting stents (DES) have become the most widely used devices worldwide for management of coronary artery disease. As remote follow-up data were becoming available, concerns emerged in regard to their long-term safety. Second-generation DES were designed to overcome safety issues, but the results of randomised clinical trials remain conflicting.MethodsWe compared the safety and efficacy of first-generation versus second-generation Food and Drug Administration approved DES; the following devices were included: first-generation sirolimus-eluting stent (SES) and paclitaxel-eluting stents (PES); second-generation everolimus-eluting stent (EES), zotarolimus-eluting stent Endeavor and ZES-Resolute (ZES-R). Prespecified safety end points comprised ≤1 and >1 year: overall and cardiac mortality, myocardial infarction (MI), definite/definite or probable ST; efficacy end points were target lesion revascularisation and target vessel revascularisation. Composite end points were analysed as well.Results33 randomised controlled trials involving 31 379 patients with stable coronary artery disease or acute coronary syndrome undergoing DES implantation were retrieved. No differences in mortality among devices were found. In the overall class comparison, second-generation DES were associated with a 22% reduction of odds of MI at short-term OR 0.77 (95% CI 0.68 to 0.89) p=0.0002; EES reduced the odds of definite-probable ST compared with PES: OR 0.33 (95% CI 0.15 to 0.73) p=0.006; First-generation SES along with second-generation EES and ZES-R showed similar efficacy in decreasing the odds of repeat revascularisation.ConclusionsSecond-generation EES and ZES-R offer similar levels of efficacy compared with first-generation SES, but are more effective than PES; however, only second-generation EES significantly reduced the incidence of MI and ST, and therefore should be perceived as the safest DES to date.

Survival Benefits of Invasive Versus Conservative Strategies in Heart Failure in Patients With Reduced Ejection Fraction and Coronary Artery Disease

“…(2) In HF patients, CAD tends to be more complex and diffuse, leading to higher need for RRs and MI rates after coronary stenting than with CABG. 37,38 (3) CABG revascularization of prolonged epicardial segments versus PCI performed only on specific stenotic lesion can yield a better vessel patency due to often extensively diseased arteries in ischemic HF. (4) In HF patients with low cardiac reserve, it is conceivable that in-stent restenosis would be more negatively impacting in this group than in others without severe dysfunction.…”

Long-Term Clinical Outcomes of Fractional Flow Reserve–Guided Versus Routine Drug-Eluting Stent Implantation in Patients With Intermediate Coronary Stenosis

“…Third, our study was performed in first-generation DES era, and recent reports have shown that second-generation DESs have more favorable clinical outcomes than first-generation DES. [17][18][19] Fourth, the information on the angina status and antianginal medication was not available in this study. Finally, because this study was designed before FAME studies, PCI indication in the FFR-guided group was FFR<0.75.…”

Drug-eluting balloons with provisional bail-out or adjunctive stenting in de novo coronary artery lesions—a systematic review and meta-analysis

“…Also, the relatively short contact time between DEB and vessel wall could result in a greater 'wash-off' effect than with DES. A study investigating DEB techniques found optimal concentrations of paclitaxel in the vessel wall following Cardiovasc Diagn Ther 2018;8 (2) (41,42). Thus, it cannot be ruled out that some heterogeneity within results arose from a lack of uniformity in the DEB and DES employed.…”