Most literature describing stent-related major adverse cardiovascular events (MACE) following percutaneous coronary intervention (PCI) consider only the first year post-intervention. Very little is known about the frequency and predictors of very-late stent-related events (>1 year and ≤5 years post-intervention), or MACE by stent type. This large-scale, individual patient data pooled study by Madhaven et. al. addresses this gap.
Madhaven et. al. pooled data from across 19 prospective, randomized metallic stent trials. The data tracked outcomes of 25,032 patients: 3718 treated with bare-metal stents (BMS), 7934 with first-generation drug-eluting stents (DES1), and 13,380 with second-generation drug-eluting stents (DES2). The team analyzed MACE and target lesion failure (TLF) occurring within the first year, and between years 1 and 5 post-PCI. Very late MACE encompassed cardiac death, myocardial infarction (MI), and ischemia-driven target lesion revascularization (ID-TLR). TLF comprised cardiac death, target vessel MI, or ID-TLR. Events were compared across BMS, DES1 and DES2.
Stent-related events over 1 year after PCI
MACE within 1 year occurred in 8.0% of patients; very-late MACE in 9.4% of patients, and TLF in 8.2% of patients. When considered by stent type, MACE rates were highest with BMS (17.9%) and lowest in DES 2 (5.1%). Very-late MACE occurred in 9.7%, 11.0%, and 8.3% of patients treated with BMS, DES1, and DES2, respectively (p<0.0001), with a linear increase noted between 1 and 5 years. The authors discovered that the highest rate of both very-late MACE and TLF occurred with DES1 stents. Very-late stent-related ischemic events occurred at a rate of ⁓2%/year after PCI with all metallic stents, with no evident plateau. Diabetes mellitus, recent smoking, prior revascularization and prior MI were all significant predictors of very-late MACE and TLF.
Since many patients given stents will survive for ≥20 years, very-late events may occur in >50% of patients. As such, stent-derived adverse events represent a considerable lifelong health risk to patients with coronary artery disease. Madhaven et. al recommend the aggressive management of accompanying predictors of very-late MACE and TLF to ultimately achieve better long-term outcomes.
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Author: Kelly Schoonderwoerd
Original Article: JACC. 2020 Feb 18; 75(6): 590-604