Selective use of contemporary drug-eluting stents in primary angioplasty for ST-elevation myocardial infarction: pooled analysis of COMFORTABLE AMI and EXAMINATION

Abstract

Aims: Selective use of DES only in patients at higher risk of MACE is common practice, particularly in healthcare systems with a large premium payable for DES. We aimed to identify subgroups of patients in which the use of BMS in primary percutaneous coronary intervention (PPCI) for STEMI can still be justified.Methods and results: We performed a patient-level pooled analysis of COMFORTABLE AMI and EXAMINATION comparing contemporary DES with BMS in PPCI. A risk score was applied using three parameters: lesion length >15 mm, vessel size <3 mm, and diabetes mellitus. Individual data were available for 2,655 patients. The incidence of MACE at one year was incrementally higher in patients with risk scores of 1 or 2/3. MACE rates were lower in patients with a risk score 0 or 1 who were treated with DES (p=0.0073 and p=0.008). No difference in death or reinfarction was seen between DES and BMS in any group. There was a significant reduction in TLR with DES in all three groups.Conclusions: A score comprising vessel size, lesion length, and diabetes did not identify patients at low risk with equivalent or better results from BMS use. The results suggest that the practice of only selective use of DES in primary PCI should be discouraged. KEYWORDS• drug-eluting stents • primary angioplasty • STEMI

Socioeconomic Status and Prognosis of Patients With ST-Elevation Myocardial Infarction Managed by the Emergency-Intervention “Codi IAM” Network

“…The lower tendency of use of DESs in the low-SES group observed in our study has also been reported in American cohorts ( 30 – 32 ), which is a “treatment-risk paradox” in which higher-risk patients are not treated with optimal or evidence-based strategies, and the use of mechanical support devices is reduced, and it may result in prognosis worsening ( 19 , 33 , 34 ). This finding may reflect the fact that differences in outcomes may not only be related to the use of a specific treatment/device in the acute period but to a whole standardized medical approach in which access to secondary prevention may be of utmost importance ( 35 ) and that the health system may override the burden of higher risk subsets.…”