Monday, July 21, 2014

STABLE ANGINA PECTORIS. SHOULD WE OR SHOULD WE NOT, REVASCULARISE? NEW DATA POST COURAGE



The interventional world was noticeably shaken in 2007 with the release of the COURAGE trial ( Dr William Bolden ) that optimal medical therapy was as good as PCI in the management of stable angina pectoris. That paper caused many interventional cardiologist to rethink their strategy. Of course the noise level came up that optimal medical therapy was very intensive an "optimal" ( more "optimal" than was practised by many institution at that time ) and PCI was done with mainly bare-metal stents ( this was 2007 ), or just plain old balloon angioplasty. Those were the days.
Of course since then stents have improved in design and also technology from bare metal to 1st generation drug eluting and now 2nd generation drug eluting, and today even 3rd generation drug eluting stents and even bioabsorbable vascular scaffolding. Things have gotten along and clinical trials are always behind the curve.

Well these advances prompted Dr Stephen Windecker and colleagues to re-visit this question with a meta-analysis of data from 1998-2013 of 100 randomised trial of medical therapy Vs PCI with second generation DES. It included all RT ( randomised trials ) with an enrolment of at least 100 patients in each arm ( medical therapy Vs PCI )  and which had a t least 6 months follow up.This paper was published in the June 23rd BMJ. There were 93, 553 patients in total, in the 100 RT analysed.

Rate Ratio (95% CI) for Outcomes by Revascularization Method vs Med-Based Strategy for Stable CAD in Meta-Analysis
Revascularization methodEnd points
All-cause mortality, 95 trials (n=93 553)MI, 92 trials (n=90 472)Revascularization, 94 trials (n=90 282)
CABG0.80 (0.70–0.91)0.79 (0.63–0.99)0.16 (0.13–0.20)
Balloon angioplasty0.85 (0.68–1.04)0.88 (0.70-1.11)0.97 (0.82–1.16)
Bare-metal stent0.92 (0.79–1.05)1.04 (0.84–1.27)0.44 (0.59–0.82)
"New-generation" DES
Everolimus0.75 (0.59–0.96)0.75 (0.55–1.01)0.27 (0.21–0.35)
Zotarolimus (Resolute)0.65 (0.42–1.00)0.82 (0.52–1.26)0.26 (0.17–0.40)
"Early-generation" DES
Paclitaxel0.92 (0.75–1.12)1.18 (0.88–1.54)0.44 (0.35–0.55)
Sirolimus0.91 (0.75–1.10)0.94 (0.71–1.22)0.29 (0.24–0.36)
Zotarolimus (Endeavor)0.88 (0.69–1.10)0.80 (0.56–1.10)0.38 (0.29–0.51)

Basically, the results showed that PCI with 2nd generation DES came out better for patients with chest pains and also asymptomatic CAD.
This paper showed me that the pendulum is still swinging and the definitive answer is still unknown. This is obviously because stents are getting better and that is the way it should be. The second lesson that I learn from this paper is that not all stents are the same. There are significant differences between the bare metal, 1st generation and 2nd generation DES. The difference between the 2nd and 3rd generation, in my opinion is minimal. When we talk about the second generation DES, we are talking about the everolimus eluting Xience V and the Zotarolimus eluting Endeavor Resolute. I suppose by extension also the Promus Element, although the data is scarce here.
I am very concern that all over town and this country, generic stents are being implanted left right and center, on unsuspecting patients who were being told that all stents are the same. This I believe is also being done in Public Hospitals where cost is a constrain, so cheap DES ( non FDA approved ) are being used in significant number on the assumption that all stents are the same and patients don't know better.This is simply not fair.

Well, maybe this blog posting will serve to further inform the public, though limited in its outreach.




1 comment:

I Love Teh Tarik! said...

Thank you doctor. You are very kind by helping to spread the knowledge on the different types of stents available.

I hope that the public will be more educated about the different types of stents available, and ask more questions when there is a need.

Be blessed.