Outcomes With Various Stents in Diabetic Patients
Outcomes With Various Stents in Diabetic Patients
Objectives To evaluate the efficacy and safety of currently used drug eluting stents compared with each other and compared with bare metal stents in patients with diabetes.
Design Mixed treatment comparison meta-analysis.
Data sources and study selection PubMed, Embase, and CENTRAL were searched for randomised clinical trials, until April 2012, of four durable polymer drug eluting stents (sirolimus eluting stents, paclitaxel eluting stents, everolimus eluting stents, and zotarolimus eluting stents) compared with each other or with bare metal stents for the treatment of de novo coronary lesions and enrolling at least 50 patients with diabetes.
Primary outcomes Efficacy (target vessel revascularisation) and safety (death, myocardial infarction, stent thrombosis).
Results From 42 trials with 22,844 patient years of follow-up, when compared with bare metal stents (reference rate ratio 1) all of the currently used drug eluting stents were associated with a significant reduction in target vessel revascularisation (37% to 69%), though the efficacy varied with the type of stent (everolimus eluting stents~sirolimus eluting stents>paclitaxel eluting stents~zotarolimus eluting stent>bare metal stents). There was about an 87% probability that everolimus eluting stents were the most efficacious compared with all others, though there were limited usable data for the zotarolimus eluting Resolute stent in patients with diabetes. Moreover, there was no increased risk of any safety outcome (including very late stent thrombosis) with any drug eluting stents compared with bare metal stents. There was about a 62% probability that the everolimus eluting stent was the safest stent for the outcome of “any” stent thrombosis.
Conclusions Among patients with diabetes treated with coronary stents all currently available drug eluting stents were efficacious without compromising safety compared with bare metal stents. There were relative differences among the drug eluting stents, such that the everolimus eluting stent was the most efficacious and safe.
The presence of diabetes has been associated with worse outcomes after percutaneous coronary intervention with bare metal stents and drug eluting stents. While drug eluting stents have reduced the risk of restenosis, there is controversy as to the relative efficacy of various drug eluting stents in patients with diabetes. Several subgroup analyses from patients with diabetes enrolled in randomised clinical trials, pooled analyses from the diabetic subgroups of randomised controlled trials, and several registry studies suggest that the paclitaxel eluting stent might provide similar benefits to sirolimus eluting stents and everolimus eluting stents. Other analyses derived from randomised controlled trials, however, have reached different conclusions, showing sirolimus eluting stents to be superior to paclitaxel eluting stents. Dedicated randomised controlled trials in patients with diabetes have shown that sirolimus eluting stents are superior to paclitaxel eluting stents. The long term efficacy and safety of the various drug eluting stents and bare metal stents in patients with diabetes is therefore controversial. This issue has important implications for the selection of the most effective treatment in these high risk patients. Accordingly, we examined the relative safety and efficacy of various drug eluting stents compared with bare metal stents and each other among patients with diabetes.
Abstract and Introduction
Abstract
Objectives To evaluate the efficacy and safety of currently used drug eluting stents compared with each other and compared with bare metal stents in patients with diabetes.
Design Mixed treatment comparison meta-analysis.
Data sources and study selection PubMed, Embase, and CENTRAL were searched for randomised clinical trials, until April 2012, of four durable polymer drug eluting stents (sirolimus eluting stents, paclitaxel eluting stents, everolimus eluting stents, and zotarolimus eluting stents) compared with each other or with bare metal stents for the treatment of de novo coronary lesions and enrolling at least 50 patients with diabetes.
Primary outcomes Efficacy (target vessel revascularisation) and safety (death, myocardial infarction, stent thrombosis).
Results From 42 trials with 22,844 patient years of follow-up, when compared with bare metal stents (reference rate ratio 1) all of the currently used drug eluting stents were associated with a significant reduction in target vessel revascularisation (37% to 69%), though the efficacy varied with the type of stent (everolimus eluting stents~sirolimus eluting stents>paclitaxel eluting stents~zotarolimus eluting stent>bare metal stents). There was about an 87% probability that everolimus eluting stents were the most efficacious compared with all others, though there were limited usable data for the zotarolimus eluting Resolute stent in patients with diabetes. Moreover, there was no increased risk of any safety outcome (including very late stent thrombosis) with any drug eluting stents compared with bare metal stents. There was about a 62% probability that the everolimus eluting stent was the safest stent for the outcome of “any” stent thrombosis.
Conclusions Among patients with diabetes treated with coronary stents all currently available drug eluting stents were efficacious without compromising safety compared with bare metal stents. There were relative differences among the drug eluting stents, such that the everolimus eluting stent was the most efficacious and safe.
Introduction
The presence of diabetes has been associated with worse outcomes after percutaneous coronary intervention with bare metal stents and drug eluting stents. While drug eluting stents have reduced the risk of restenosis, there is controversy as to the relative efficacy of various drug eluting stents in patients with diabetes. Several subgroup analyses from patients with diabetes enrolled in randomised clinical trials, pooled analyses from the diabetic subgroups of randomised controlled trials, and several registry studies suggest that the paclitaxel eluting stent might provide similar benefits to sirolimus eluting stents and everolimus eluting stents. Other analyses derived from randomised controlled trials, however, have reached different conclusions, showing sirolimus eluting stents to be superior to paclitaxel eluting stents. Dedicated randomised controlled trials in patients with diabetes have shown that sirolimus eluting stents are superior to paclitaxel eluting stents. The long term efficacy and safety of the various drug eluting stents and bare metal stents in patients with diabetes is therefore controversial. This issue has important implications for the selection of the most effective treatment in these high risk patients. Accordingly, we examined the relative safety and efficacy of various drug eluting stents compared with bare metal stents and each other among patients with diabetes.
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