DES Linked With Lower In-Hospital Mortality Than BMS for All PCI Indications
Download this article's Factoid (PDF & PPT for Gold Subscribers)
Using drug-eluting stents (DES) instead of bare-metal stents (BMS) appears to lower the risk of in-hospital mortality across indications for percutaneous coronary intervention (PCI) and several high-risk subgroups, according to an observational study published online September 14, 2014, ahead of print in the American Journal of Cardiology.
“In acute settings and when [the] patient-physician relationship is uncertain, physicians are sometimes reluctant to use DES,” Apurva O. Badheka, MD, of Yale-New Haven Hospital (New Haven, CT), told TCTMD in an email. But based on these results, he added, “we believe that DES should be used preferentially over BMS when feasible. Especially since the newer-generation DES are vastly superior stents in complex patients and lesion subsets as compared to BMS.”
Methods
Dr. Badheka and colleagues examined data from 665,804 stent procedures—76.81% with DES and 23.19% with BMS—collected in the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample from 2006 to 2011, representative of nearly 3.3 million PCIs performed in the United States over that span. The researchers excluded procedures in which both DES and BMS were used.
The mean age of the patients was 64.3 years, and two-thirds were men. Most of the procedures (70.7%) were emergent, and 40.7% of patients underwent PCI for an acute MI.
Early Outcomes Better
With DES
The rate of in-hospital mortality (primary outcome) was lower with DES than with BMS (0.49% vs 1.43%; P < .001), a difference that remained significant on multivariate analysis (OR 0.59; 95% CI 0.54-0.64) and propensity-matched analysis (0.7% vs 1.2%; P < .001).
The mortality difference was consistent across high-risk subgroups, including patients with diabetes, acute MI/shock, or multivessel disease and those older than 80 years (P < .001 for all).
Aside from BMS use, other predictors of higher in-hospital mortality included greater burden of comorbidity (OR 2.70), older age (OR 1.05), female sex (OR 1.19), MI (OR 3.83), and shock (OR 15.26; P < .001 for all), with similar findings in a model that included operator volume. Higher operator (OR 0.74) and hospital volumes (OR 0.71) were associated with lower in-hospital mortality.
Complications also were less frequent with DES than BMS (4.6% vs 6.9%), with lower rates of postprocedural vascular, cardiac, and respiratory problems (P < .001 for all). Postoperative venous thromboembolism was slightly less common with DES (0.4% vs 0.6%; P < .001).
In addition, in the propensity-matched analysis, use of DES instead of BMS was associated with shorter hospital stay (2.7 vs 2.9 days) but higher average cost ($18,153 vs $15,692; P < .001 for both).
Mortality Benefit Still Questionable
Even though DES have been shown to reduce the risk of both in-stent restenosis and long-term TVR compared with BMS, data on a potential mortality benefit have been “questionable at best,” Dr. Badheka said. “This lack of survival differences in RCTs has been partly attributed to the select low-risk study populations as well as relatively smaller sample sizes. Moreover, several comparative studies have not included the latest generation of DES.”
“We firmly believe that newer generations of DES provide superior short-term outcomes compared to BMS and should be the ‘go to’ stents for most clinical scenarios,” he added. “This is also reflected in contemporary clinical practice. Our study results provide confirmation for this hypothesis.”
However, Robert W. Yeh, MD, MBA, of Massachusetts General Hospital (Boston, MA), told TCTMD in a telephone interview that the mortality disparity might not be related to stent type.
“Similar to prior studies, the results show that cardiologists reserve bare-metal stenting for a much sicker population of patients compared with patients receiving DES,” he said. “The in-hospital mortality differences, even after adjustment, are most likely due to unmeasured differences in the comorbidities of patients receiving the different stent types, as opposed to differences conferred by the stents themselves.”
He added that observational analyses comparing DES and BMS are complicated by “the high degree of selectivity that physicians use in choosing stent types for their patients. Although recent studies have taught us that newer-generation DES are likely associated with better long-term outcomes than BMS, I think it would be wrong to conclude from this analysis that the simple act of choosing a DES over a BMS will lead to significant in-hospital mortality reductions in our patients.”
The researchers acknowledge some limitations of the study, including the inability to establish causal relationships and the use of administrative data on inpatient admissions, which raises the possibility of coding errors and precludes the evaluation of long-term outcomes and various clinical parameters like antiplatelet use.
Source:
Badheka AO, Arora S, Panaich SS, et al. Impact on
in-hospital outcomes with drug eluting stents versus bare metal stents (from
665,804 procedures). Am J Cardiol.
2014;Epub ahead of print.
Related Stories:
Todd Neale is the Associate News Editor for TCTMD and a Senior Medical Journalist. He got his start in journalism at …
Read Full BioDisclosures
- Drs. Badheka and Yeh report no relevant conflicts of interest.
Comments