Transcript Major Adverse Cardiac Events Rates after Bare Metal
Tarunjit Singh Department of Internal Medicine Westchester Medical Center New York Medical College Valhalla NY
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.
Defined as occurrence of one of the following :
Myocardial Infarction
Target Vessel Revascularization
Death
Prehospital Fibrinolysis
Improvement in survival Smaller infarct size Improved ventricular healing Reduction in the extent of left ventricular dysfunction Greater electrical stability
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.
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
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 Fisher’s exact test were done for categorical variables.
Student’s T test were done for continuous variables.
Variable Age (years) Male Female Smoking Hypertension Dyslipidemia Diabetes mellitus BMI ≥ 30 kg/m² BMS (n= 102) 64 ± 12 73 (72%) 29 (28%) 48 (45%) 94 (92%) 99 (97%) 39 (38%) 34 (33%) DES (n= 274) 63 ± 12 197 (72%) 77 (28%) 98 (36%) 263 (96%) 266 (97%) 118 (43%) 65 (24%) P value ns ns ns ns ns ns ns ns
Variable Aspirin use Clopidogrel use Beta blockers use 90 (88%) Ace Inhibitor use 45 (44%) Statin use Follow-up (months) Coronary artery bypass grafting BMS 101 (99%) DES 271 (99%) P value ns 102 (100%) 274 (100%) ns 99 (97%) 42 ± 19 13 (13%) 260 (95%) 129 (47%) 271 (99%) 43 ± 15 18 (7%) ns ns ns ns ns
No of vessel diseased 1-vessel disease BMS DES P value 53 (52%) 134(49%) Ns 2 vessel disease 22 (22%) 89 (32%) Ns 3 vessel disease 27 (26%) 51 (19%) Ns
Lesion Complexity Type A 34 (33%) 106 (39%) P value ns Type B 29 (29%) 95 (34%) ns Type C 39 (38%) 73 (27%) Stent length (mm) 27 Stent width (mm) ± 15 3.2 ± 0.6
25 ± 14 3.0 ± 0.3
ns ns <.0001
Variable Myocardial infarction TVR BMS (n=102) 4 (4%) 16 (16%) Death MACE 12 (12%) 25 (25%) DES (n=204) 8 (3%) 27 (10%) 14 (5%) 40 (15%) P value ns ns 0.024
0.024
Prognostic Factors Parameter Estimate Standard Error P value
0.339
0.019
Prior coronary artery surgery Width of stent 0.797
-0.816
0.296
0.006
Bare-metal stent 0.604
0.259
0.019
Hazard Ratio
2.218
0.442
1.830
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.