Comparison Among Ultra-Thin Coronary Stents: A Network Meta-Analysis

Evolution of coronary stents: innovations, antithrombotic strategies and future directions

Implantation of drug-eluting stents (DESs) remains central to percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) and chronic coronary syndromes (CCS). DES platforms, polymers and drugs have evolved significantly to improve deliverability and safety, now being typically thin-strut with a compact layer of biocompatible or bioresorbable polymer, or no polymer at all. Ultra-thin-strut DESs push this concept further, and in some studies perform better than conventional DES, but may recoil in challenging settings such as chronic total occlusion PCI. Stent implantation has also progressed, with greater attention to lesion preparation and poststenting optimisation, increased use of intracoronary imaging helping to recognise and remedy issues. In parallel, antithrombotic therapy for patients undergoing PCI has advanced considerably, with reliable P2Y12 inhibition now possible with the newest agents. As well as progress in controlling other thrombotic risk factors such as hyperlipidaemia, hypertension and diabetes, these developments have contributed to reducing thrombotic risk. As well as preventing stent thrombosis, antithrombotic therapy can reduce the risk of non-PCI-related thrombotic events, not only in the coronary tree but also in the cerebral and peripheral circulation, however it increases bleeding risk. Twelve months of dual antiplatelet therapy (DAPT) after PCI for ACS (and 6 months after PCI for CCS) remains the default recommended strategy, but given reliable P2Y12 inhibition, good control of ischaemic risk factors and a minimally thrombogenic stent design and deployment, it is rational that earlier de-escalation to monotherapy, particularly with ticagrelor, is often appropriate, reserving longer-duration DAPT for those with highest ischaemic risk but where bleeding risk is not high. A body of trial evidence now supports this. As well as earlier de-escalation of DAPT, future developments in PCI might include increased use of 'leave nothing behind' strategies and further pharmacological options for optimisation of ischaemic risk factors.

[[The ultrathin-strut everolimus-eluting stent in a real-world population: the Everythin multicenter registry]]

Introduction and objectives

Ultrathin-strut stents (UTS) represent a significant advancement in percutaneous coronary intervention. This study aimed to evaluate the safety and short- to mid-term outcomes of stenting with the thinnest struts on the market (50 µm) using a biodegradable everolimus-eluting polymer (Evermine 50) in real-world patients with coronary artery disease.

Methods

A single-arm, multicenter, prospective study was conducted in real-world patients. A total of 161 patients with de novo lesions who received at least 1 UTS stent were enrolled. The primary safety endpoint was the occurrence of major adverse cardiovascular events, defined as cardiac death, target-vessel myocardial infarction, or the need for revascularization of the target lesion at 12 months. The incidence of stent thrombosis at 12 months was also analyzed.

Results

The study included 161 patients with a mean age of 64 ± 14 years; 79% were male, 34% had diabetes, and 66% had hypertension. The most common indication for intervention was non-ST-segment elevation myocardial infarction (42%), followed by ST-segment elevation myocardial infarction (22%). The procedural success rate was 100%. At 12 months of follow-up, the incidence of MACE was 2.5%, and the definite stent thrombosis rate was 1.3%.

Conclusions

The use of the 50 µm UTS stent with a biodegradable everolimus-eluting polymer demonstrated a favorable safety profile and good clinical outcomes in unselected patients at 1 year of follow-up.

Invasive and conservative management of elderly patients presenting with acute coronary syndrome: A meta-analysis of randomized controlled trials and adjusted observational studies

BACKGROUND

Elderly patients are often under-represented in studies about coronary revascularization in acute coronary syndromes (ACS) and undertreated in clinical practice. We sought to evaluate differences in outcomes between an initial invasive or conservative strategy in this subset of patients, METHODS: The analysis was performed following PRISMA guidelines. Randomized controlled trials (RCTs) and adjusted observational studies comparing an invasive and conservative strategy in old patients with ACS were systematically identified. Random or fixed effect model was used accordingly to heterogeneity testing results. Short-term mortality was the primary outcome. 30-day and longer-term re-infarction, MACE and all-cause mortality were secondary endpoints. Sensitivity analysis including RCTs only were performed for the primary endpoint and 1 year mortality and another analysis, stratifying NSTEMI and STEMI studies, was performed for short-term mortality.

RESULTS

Invasive management was associated with lower short and long-term mortality (30 days OR 0.64, 95 % CI 0.54-0.76, p < 0.001; 1 year HR 0.60, 95 % CI 0.52-0.78, p < 0.001; Long-term HR 0.62, 95 % CI 0.55-0.71, p < 0.001) compared to a conservative strategy. In the short-term follow-up, the benefit was preserved when differentiating for NSTEMI or STEMI studies but not when considering only RCTs. Major bleedings were more frequent in the invasive group (30 days OR 1.61, 95 % CI 1.39-1.87, p < 0.001). The mean difference in length of stay was not significantly different between the two strategies (mean difference in days 0.14, 95 % CI -0.79 to 1.06, p = 0.77).

CONCLUSION

An initial invasive strategy might lead to reduced short and long-term mortality in elderly patients presenting with acute coronary syndrome but it is associated with increased bleeding events rate. No difference in hospital stay length was observed. Results were mainly driven by non-randomized studies.