Major Adverse Cardiac Event Rates after Bare- Metal Stenting Versus Drug-Eluting Stenting in Patients with Acute ST-Segment Elevation Myocardial Infarction Undergoing Thrombolysis and Percutaneous Coronary Intervention

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Major Adverse Cardiac Event Rates after
Bare- Metal Stenting Versus Drug-Eluting
Stenting in Patients with Acute ST-Segment
Elevation Myocardial Infarction Undergoing
Thrombolysis and Percutaneous Coronary
Intervention

• Tarunjit Singh
• Department of Internal Medicine
• Westchester Medical Center
• New York Medical College
• Valhalla NY

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Aims and Objectives

• To compare Major Adverse Cardiac Events (MACE) in
  Bare- metal versus drug-eluting stent in patients
  treated with TNK prior to being admitted to our
  facility for PCI.

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Major Adverse Cardiac events (MACE)

• Defined as occurrence of one of the following
  
• Myocardial Infarction
• Target Vessel Revascularization
• Death

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Introduction

• Prehospital Fibrinolysis
• Improvement in survival
• Smaller infarct size
• Improved ventricular healing
• Reduction in the extent of left ventricular
  dysfunction
• Greater electrical stability

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Fibrinolytic Agents And Trials

• GISSI-2 and ISIS-2 Streptokinase
• GUSTO-I trial Alteplase
• GUSTO III trial compared Reteplase with Alteplase
  
• ASSENT-2 compared Tenecteplase to Alteplase
• The net effect in major thrombolytic trials has
  been an approximately 30 percent reduction in
  short-term mortality to a value of 7 to 10
  percent.

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Time to thrombolysis and 35-day mortality
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• PCI after fibrinolysis
• There are three settings in which Percutaneous
  Coronary Intervention (PCI) is performed after
  fibrinolysis
• Facilitated PCI, in which a fibrinolytic drug is
  given prior to planned PCI in an attempt to
  achieve an open infarct-related artery before
  arrival in the catheterization laboratory
• Rescue / Salvage PCI is defined as PCI performed
  within 12 hours of failed fibrinolysis (primary
  failure) in patients with evidence of continuing
  or recurrent myocardial ischemia

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Methods

• Analysis of 376 consecutive patients ,out of
  which 102 received BMS and 274 received DES from
  2003 to 2005.
• The 376 patients were followed for a period of
  43 17 months.
• End point of follow-up was occurrence of MACE.
• Choice of stent type was at the discretion of the
  operator.
• Chi-square or Fishers exact test were done for
  categorical variables.
• Students T test were done for continuous
  variables.

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Results
Variable BMS (n 102) DES (n 274) P value
Age (years) 64 12 63 12 ns
Male 73 (72) 197 (72) ns
Female 29 (28) 77 (28) ns
Smoking 48 (45) 98 (36) ns
Hypertension 94 (92) 263 (96) ns
Dyslipidemia 99 (97) 266 (97) ns
Diabetes mellitus 39 (38) 118 (43) ns
BMI 30 kg/m² 34 (33) 65 (24) ns
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Results
Variable BMS DES P value
Aspirin use 101 (99) 271 (99) ns
Clopidogrel use 102 (100) 274 (100) ns
Beta blockers use 90 (88) 260 (95) ns
Ace Inhibitor use 45 (44) 129 (47) ns
Statin use 99 (97) 271 (99) ns
Follow-up (months) 42 19 43 15 ns
Coronary artery bypass grafting 13 (13) 18 (7) ns
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Cardiac Catheterization findings
No of vessel diseased BMS DES P value
1-vessel disease 53 (52) 134(49) Ns
2 vessel disease 22 (22) 89 (32) Ns
3 vessel disease 27 (26) 51 (19) Ns
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Cardiac Catheterization findings
Lesion Complexity Lesion Complexity Lesion Complexity Lesion Complexity P value
Type A 34 (33) 106 (39) 106 (39) ns
Type B 29 (29) 95 (34) 95 (34) ns
Type C 39 (38) 73 (27) 73 (27) ns
Stent length (mm) 27 15 25 14 25 14 ns
Stent width (mm) 3.2 0.6 3.0 0.3 3.0 0.3 lt.0001
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Incidence of MACE
Variable BMS (n102) DES (n204) P value
Myocardial infarction 4 (4) 8 (3) ns
TVR 16 (16) 27 (10) ns
Death 12 (12) 14 (5) 0.024
MACE 25 (25) 40 (15) 0.024
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Cox Regression analysis for independent
prognostic factors for MACE
Prognostic Factors Parameter Estimate Standard Error P value Hazard Ratio
Prior coronary artery surgery 0.797 0.339 0.019 2.218
Width of stent -0.816 0.296 0.006 0.442
Bare-metal stent 0.604 0.259 0.019 1.830
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RESULTS

• Prior CABG surgery, Decreased stent width and
  the use of bare-metal stents (BMS) were
  independent risk factors for MACE.
• BMS had a 1.8 times higher incidence of
  developing MACE as compared to DES.
• No increased rate of acute or chronic thrombosis
• after thrombolysis in either group.
• The increased rate of MACE in BMS group may
  be attributed to increased incidence of
  restenosis.

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• THANK YOU

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