DES: The Year in Review

MIAMI FLA.—Data from the past year clearly demonstrate that differing trends in PCI frequency and DES utilization are emerging around the world, said TCT Course Director Martin B. Leon, MD, of Columbia University Medical Center in New York, during his keynote address at the Drug-Eluting Stent Summit.

Utilization of PCI procedures worldwide is rising, he said, and is expected to increase through 2015. By region, PCI procedures are growing in the Asia Pacific, declining in the United States, and remaining relatively flat in Europe and other parts of the world. The majority of US interventional cardiologists expect the number of PCIs to continue to decline through 2013, according to data presented by Leon.

Significant regional variation in PCI growth patterns and DES penetration is driven by a variety of factors, including appropriate use criteria issues in the United States and cost issues worldwide.

“Appropriate use criteria is the largest driver of PCI decline in the United States, and is expected to continue,” Leon said, adding that in the United States it accounts for about 57% of the decline and will be a continued area of focus in the year to come. Leon also noted strong evidence that underutilization of coronary revascularization is associated with a significant increase in the risk for adverse outcomes, and cautioned that appropriate use should be looked at from both sides.

Trends in 2012

Leon highlighted changing trends in the past year, including the increasing use of transradial access, outpatient PCI for stable patients and ischemia-driven PCI, particularly fractional flow reserve (see Figure).

Importantly, he said, there has been a paradigm shift from “old” to “new” DES, especially bioabsorbable polymers, based on evidence for improved outcomes.

“First-generation DES are now essentially gone,” he said during the session. “Second-generation DES are viewed with much greater favor.”

The year ahead

Recent data have suggested that neoatherosclerosis is emerging as a new DES-related concern in terms of thrombosis and restenosis. Second-generation and newer-version DES may have particular advantages with regard to this outcome, he added.

Duration of dual antiplatelet therapy (DAPT) remains controversial, Leon observed. The clear trend is for shorter-term DAPT — 3 to 6 months — especially with newer DES and in stable clinical scenarios.

In addition, many new studies are being conducted in lesion subsets, such as left main and STEMI, which may yield important results.

Regarding the development of new technologies, Leon concluded, “It is going to be interesting to see how DES in their current metallic scaffold version will stack up to the new kid on the block — bioabsorbable scaffolds.”