In Acute MI Patients, Early QoL Advantage With DES Over BMS Disappears by 1 Year
While a reduction in restenosis is 1 touted benefit of DES vs BMS, the impact of this difference on quality of life (QoL) in acute MI patients is minimal at 6 months and gone by 1 year, according to a study published online July 26, 2015, ahead of print in the American Heart Journal.
“These findings suggest that stent type does not significantly impact long-term health status,and that the primary long-term benefits of DES are limited to the avoidance of additional revascularization procedures, rather than improvements in quality of life,” write Adnan K. Chhatriwalla, MD, of Saint Luke’s Mid America Heart Institute (Kansas City, MO), and colleagues.
The investigators analyzed data from the TRIUMPH and PREMIER registries on 2,694 acute MI patients (mean age 59 years; 70% men) who received DES (n = 1,361) or BMS (n = 1,333) between 2003 and 2008. All patients were assessed using the following QoL measurements:
- Seattle Angina Questionnaire (SAQ)
- Medical Outcomes Study Short Form-12 (SF-12)
- Eight-item Patient Health Questionnaire (PHQ-8)
Most patients presented with STEMI (59.5%), while multivessel disease was diagnosed in 41%.
QoL Evens Out Over Time
At both 6- and 12-month follow-up, improvements in QoL compared with baseline were seen on all 3 assessments, regardless of stent type.
However, in a propensity-matched analysis of 784 pairs, DES treatment was associated with greater improvements in SAQ scores for QoL and physical limitation than BMS at 6 months but not at 12 months (table 1). In fact, DES use was linked with a 1.7-point lower SAQ score for treatment satisfaction compared with BMS at 12 months (P = .031).
There were no differences in SAQ angina frequency, SAQ angina stability, SF-12 physical and mental components, and PHQ-8 scores between treatment groups at either 6 or 12 months. There were also no differences in medical treatment between the BMS and DES groups at either time point, with the exception of greater thienopyridine use in the DES group at 6 months and 1 year.
Additional analysis showed similar clinical response between patients receiving DES and BMS (P = .103).
However, DES use was associated with a decrease in patient-reported repeat revascularization over 1 year compared with BMS in the propensity-matched cohort (7.3% vs 10.7%; P = .017), with the difference emerging between months 6 and 12 after initial stent implantation.
Dr. Chhatriwalla and colleagues suggest 2 potential explanations for the minimal and transient advantage in QoL seen with DES.
“First, BMS restenosis may have been clinically benign in many cases, a hypothesis which is supported by prior studies [that] have documented the discrepancy between angiographic restenosis and ischemia-driven revascularization in patients undergoing routine screening angiography,” they write. “Second, patients with symptomatic restenosis may have been successfully managed, either medically or with repeat revascularization, between 6 and 12 months, minimizing the longer-term impact of initial stent choice.”
But ultimately, the data indicate that patients do not pay a “health-status penalty” because of restenosis, “whether managed medically or with repeat revascularization,” the authors say.
Benefits of DES Not Borne Out in QoL
In a telephone interview with TCTMD, Jeffrey W. Moses, MD, of Columbia University Medical Center (New York, NY), said that even though the study is based on older stent technology, it remains relevant to contemporary practice. According to Dr. Moses, the study boils down to the question: “How much does the lack of restenosis impact all these quality of life measures? And it turns out, not at all.”
But he pointed out that the analysis, even though propensity matched, does not account for all of the reasons why some patients received BMS and others DES. Device choice can be affected by factors ranging from scheduled surgery to frailty to high risk of bleeding, Dr. Moses said. “Those other factors may indicate a lower quality of life to begin with, and they may be mixed in there. So there are confounders.”
Additionally, Dr. Moses observed, prior studies comparing surgery and stenting have shown that “even though PCI obviously has more restenosis [than CABG], at 1 year the quality of life is the same. So these episodes of restenosis that are dealt with do not seem to have a huge impact on quality of life…. Their quality of life is just determined by [additional] factors other than patency of the artery.”
There is no question that DES reduce restenosis compared with BMS, he commented, adding that they also appear to reduce costs and rehospitalization rates.
“We're making an assumption that [DES use] would have an impact on quality of life, but it doesn't,” Dr. Moses added.
Chhatriwalla AK, Venkitachalam L, Kennedy KF, et al. Relationship between stent type and quality of life following percutaneous coronary intervention for acute myocardial infarction. Am Heart J. 2015;Epub ahead of print.
- Dr. Chhatriwalla reports receiving travel reimbursement from Edwards Life Sciences, Medtronic, and St. Jude Medical.
- Dr. Moses reports serving as a consultant to Abbott and Boston Scientific.