Highlights of the Year in JACC2009

Abstract

Long-term outcomes. A patient-level, pooled analysis of 4 randomized sirolimus-eluting stent (SES) trials (1) in 1,748 patients assigned to receive either an SES or bare-metal stent (BMS) showed a continued benefit of SES on target vessel revascularization (TVR) (15.2% vs. 30.1%; p Ͻ 0.0001) without differences in 5-year rate of death, myocardial infarction (MI), the composite of death/MI, or stent thrombosis (ST). The annualized rates of definite/probable ST after 1 year were 0.4% for SES and 0.2% for BMS. SES compared with BMS demonstrated superior 5-year reduction of TVR without an increase in rates of death, MI, or ST. DES in ST-segment elevation myocardial infarction (STEMI). A meta-analysis identified 13 randomized trials (n ϭ 7,352) comparing BMS versus DES in STEMI (2). Over a 2-year follow-up, DES significantly reduced TVR (relative risk [RR]: 0.44), without increasing MI or ST. Similarly, in 18 registry studies (n ϭ 26,521), DES significantly reduced TVR (RR: 0.54; 95% confidence interval) without an increase in MI. Death was significantly lower with DES within 1 year of the index percutaneous coronary intervention (PCI), but there were no differences within 2 years. The use of DES appears safe and efficacious in patients with STEMI. DES in saphenous vein grafts (SVGs).Eighty patients with 112 lesions in 88 SVGs were randomized to a BMS or paclitaxel-eluting stent (PES) (3). Binary angiographic restenosis occurred in 51% of the BMS-treated lesions versus 9% of the PES-treated lesions. During a median follow-up of 1.5 years, the PES patients had less target lesion revascularization (TLR) (28% vs. 5%) and target vessel failure (46% vs. 22%), and a trend toward less TVR (31% vs. 15%). In SVG lesions, PES are associated with lower rates of angiographic restenosis and target vessel failure than BMS. Coronary artery disease. A total of 130 patients with significant proximal left anterior descending coronary artery (LAD) coronary artery disease were randomized to either SES (n ϭ 65) or minimally invasive direct coronary artery bypass (MIDCAB) surgery (n ϭ 65) (4). Major adverse cardiac events (MACE) at 12 months occurred in 7.7% of SES patients versus 7.7% after MIDCAB (p ϭ 0.03 for noninferiority). Although noninferiority was observed in death and MI, noninferiority was not established for the difference in TVR (6.2% vs. 0%, noninferiority p ϭ 0.21). Clinical symptoms improved significantly in both treatment groups. In isolated proximal LAD disease, SES is noninferior to MIDCAB surgery at 12-month follow-up with respect to MACE at a similar relief in clinical symptoms. Coronary vasoconstriction. Coronary endothelial dysfunction was evaluated in a randomized fashion at 6 months following LAD implantation of zotarolimus-eluting stent (ZES) (n ϭ 20), SES (n ϭ 20), and BMS (n ϭ 10) (5). Incremental intracoronary acetylcholine (Ach) and nitrate infusions were given and coronary diameter evaluated in the 5-mm segments proximal and distal to the stent. In the DES groups, more intense vasoconstriction was observed at...