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Comparison of Drug-Eluting and Bare-Metal Stents for Stable Coronary Artery Disease

Brian Horst, MD^_*, Charanjit S. Rihal, MD^_*, David R. Holmes, Jr, MD^_*, John F. Bresnahan, MD^_*, Abhiram Prasad, MD^_*, Gerald Gau, MD^_*, Ryan Lennon, MS, Amir Lerman, MD^_*,_*

^_* Division of Cardiovascular Diseases and the Center for Coronary Physiology and Imaging, Mayo Clinic, Rochester, Minnesota
Division of Biostatistics, Mayo Clinic, Rochester, Minnesota

^_* Reprint requests and correspondence: Dr. Amir Lerman, Division of Cardiovascular Diseases, Mayo Clinic, Mary Brigh 4-523, First Street SW, Rochester, Minnesota 55905 (Email: Lerman.Amir{at}mayo.edu).

Objectives: The current study was designed to determine whether drug-eluting stents (DES) are superior to bare-metal stents (BMS) in patients with stable angina.

Background: Percutaneous coronary intervention has been shown to decrease symptoms of angina; its use for stable angina has not been shown to reduce myocardial infarction or mortality.

Methods: We conducted a retrospective, cross-sectional analysis of prospective data comparing the use of BMS versus DES in patients who met criteria used by the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) study investigators. The primary outcome was a composite of death, myocardial infarction, stroke, and revascularization on follow-up.

Results: The 1-year primary event rate was 15% in the DES group (95% confidence interval [CI]: 11% to 18%), compared with 27% in the BMS group (95% CI: 23% to 31%, p < 0.001). A Cox proportional hazard regression model was used to adjust for differences in patient characteristics and showed a 1-year DES hazard ratio of 0.51 (95% CI: 0.36 to 0.71, p < 0.001). After 1 year, event rates for the primary outcome increased in DES subjects relative to BMS patients, such that longer follow-up analyses resulted in nonsignificant comparisons.

Conclusions: These results suggest that the use of DES for patients with stable coronary disease is superior to BMS for 1 year, but that the increment in benefit decreased over continued follow-up. Further research is necessary to identify additional factors to promote longer-term efficacy and safety of DES.

Key Words: stable coronary disease • drug-eluting stent • bare-metal stent • myocardial infarction • mortality

Abbreviations and Acronyms   BMS = bare-metal stent(s)   CABG = coronary artery bypass grafting   CI = confidence interval   DES = drug-eluting stent(s)   HR = hazard ratio   IQR = interquartile range   MI = myocardial infarction   PCI = percutaneous coronary intervention