In Women with Coronary Artery Disease, Newer Generation Drug-eluting Stents Associated with Reduced Risks of Myocardial Infarction and Target Vessel Revascularization Compared to Bare Metal and Early Generation Drug-eluting Stents

EBM Focus - Volume 8, Issue 50

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Reference: Lancet 2013 Dec 7;382(9908):1879 (level 2 [mid-level] evidence)

Drug-eluting stents are used to reduce the risk of restenosis in patients having percutaneous coronary intervention. A Cochrane review has demonstrated that, compared to bare metal stents, drug-eluting stents reduce the risk of target lesion revascularization (Cochrane Database Syst Rev 2010 May 12;(5):CD004587). However, a large majority of patients with coronary artery disease recruited for clinical studies are male, and these trials may not have been adequately powered to make similar conclusions in women. A recent pooled analysis of individual patient data has evaluated the long-term safety and efficacy of drug-eluting stents compared to bare-metal stents in a subgroup of female patients with coronary artery disease.

A systematic review identified 26 randomized trials comparing drug-eluting stents to bare-metal stents in 43,904 patients with coronary artery disease. Individual data from 11,557 women (26.3% of randomized patients) with a mean age 67 years and a mean follow-up time of 2.9 years were included in the analysis. Drug-eluting stents were classified as either newer generation stents (including everolimus-eluting Xience and Promus stents, zotarolimus-eluting Endeavor and Resolute stents, biolimus-eluting Biomatrix and Nobori stents, and sirolimus-eluting Yukon stents) or early generation stents (sirolimus-eluting Cypher stents and paclitaxel-eluting Taxus stents). At baseline, women receiving drug-eluting stents had lower rates of diabetes and higher rates of previous myocardial infarction compared to those receiving bare metal stents. The minimum duration of dual antiplatelet therapy ranged from 2 to 12 months.

The cumulative incidence of myocardial infarction over 3 years was 4.8% in 6,278 women who received newer generation drug-eluting stents, which was significantly lower than the rates in the other groups (6% of 4,171 women with early generation drug-eluting stents and 7.7% of 1,108 women with bare metal stents). Similarly, the cumulative incidence of target lesion revascularization over 3 years was significantly reduced in the newer generation drug-eluting stent group (6.3%) compared to the other groups (7.8% with early generation and 18.6% with bare metal stents). Newer generation drug-eluting stents were also associated with significantly lower rates of definite or probable stent thrombosis. The mortality rate was 5.7% overall, with no significant differences among treatment groups.

These findings are consistent with previous findings observed for drug-eluting stents in trials evaluating populations of both women and men. Collectively, these data support the use of newer generation drug-eluting stents compared to early generation drug-eluting stents or bare-metal stents in women with coronary artery syndrome having percutaneous coronary intervention. It is important to remember that drug-eluting stents are not the preferred option in patients unable to take dual antiplatelet therapy reliably for 12 months (Circulation. 2011 Dec 6;124(23):e574-651).

For more information, see the Drug-eluting stents topic in DynaMed.