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Review
. 2008 Aug 29:337:a1331.
doi: 10.1136/bmj.a1331.

Drug eluting and bare metal stents in people with and without diabetes: collaborative network meta-analysis

Christoph Stettler  1 , Sabin Allemann, Simon Wandel, Adnan Kastrati, Marie Claude Morice, Albert Schömig, Matthias E Pfisterer, Gregg W Stone, Martin B Leon, José Suárez de Lezo, Jean-Jacques Goy, Seung-Jung Park, Manel Sabaté, Maarten J Suttorp, Henning Kelbaek, Christian Spaulding, Maurizio Menichelli, Paul Vermeersch, Maurits T Dirksen, Pavel Cervinka, Marco De Carlo, Andrejs Erglis, Tania Chechi, Paolo Ortolani, Martin J Schalij, Peter Diem, Bernhard Meier, Stephan Windecker, Peter Jüni
Affiliations
Review

Drug eluting and bare metal stents in people with and without diabetes: collaborative network meta-analysis

Christoph Stettler et al. BMJ. .

Abstract

Objective: To compare the effectiveness and safety of three types of stents (sirolimus eluting, paclitaxel eluting, and bare metal) in people with and without diabetes mellitus.

Design: Collaborative network meta-analysis.

Data sources: Electronic databases (Medline, Embase, the Cochrane Central Register of Controlled Trials), relevant websites, reference lists, conference abstracts, reviews, book chapters, and proceedings of advisory panels for the US Food and Drug Administration. Manufacturers and trialists provided additional data.

Review methods: Network meta-analysis with a mixed treatment comparison method to combine direct within trial comparisons between stents with indirect evidence from other trials while maintaining randomisation. Overall mortality was the primary safety end point, target lesion revascularisation the effectiveness end point.

Results: 35 trials in 3852 people with diabetes and 10,947 people without diabetes contributed to the analyses. Inconsistency of the network was substantial for overall mortality in people with diabetes and seemed to be related to the duration of dual antiplatelet therapy (P value for interaction 0.02). Restricting the analysis to trials with a duration of dual antiplatelet therapy of six months or more, inconsistency was reduced considerably and hazard ratios for overall mortality were near one for all comparisons in people with diabetes: sirolimus eluting stents compared with bare metal stents 0.88 (95% credibility interval 0.55 to 1.30), paclitaxel eluting stents compared with bare metal stents 0.91 (0.60 to 1.38), and sirolimus eluting stents compared with paclitaxel eluting stents 0.95 (0.63 to 1.43). In people without diabetes, hazard ratios were unaffected by the restriction. Both drug eluting stents were associated with a decrease in revascularisation rates compared with bare metal stents in people both with and without diabetes.

Conclusion: In trials that specified a duration of dual antiplatelet therapy of six months or more after stent implantation, drug eluting stents seemed safe and effective in people both with and without diabetes.

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Conflict of interest statement

Competing interests: CSt and PJ report receiving unrestricted grants from the Swiss National Science Foundation. AK receives lecture fees from Bristol-Myers Squibb, Cordis, GlaxoSmithKline, Lilly, Medtronic, Novartis, and Sanofi-Aventis. MCM receives lecture fees from Cordis, Boston Scientific, and Abbot, which go to a research organisation (RCF, Massy, France). AS receives unrestricted grant support for the Department of Cardiology he chairs from Amersham/General Electric, Bayerische Forschungsstiftung, Bristol-Myers Squibb, Cordis, Cryocath, Guidant, Medtronic, Nycomed, and Schering. MEP receives lecture fees from Medtronic. GWS receives consulting fees from Boston Scientific, Abbott, Guidant, Xtent, and BMS Imaging, lecture fees from Boston Scientific, Abbott, and Medtronic, has equity interests in Devax and Xtent, and is a member of the board of directors of Devax. MBL receives consulting fees from Cordis, Medtronic, Boston Scientific, and OrbusNeich and has equity interests in Conor, Medinol, and OrbusNeich. JJG is on the advisory board of Boston Scientific and receives research grant support from Cordis. SJP receives research grant support from Cordis. HK receives unrestricted grant support from Cordis. CSp receives consulting and lecture fees from Cordis, Boston Scientific, Abbot, Lilly, and Pfizer. MTD receives lecture fees from Boston Scientific. BM receives research grant support from various stent companies, including Cordis and Boston Scientific, and is in the speaker bureau for various stent companies, including Cordis and Boston Scientific. SW receives lecture and consulting fees from Abbot, Biotronic, Biosensors, Boston Scientific, Cordis, and Medtronic. GWS and MBL are directors of the Cardiovascular Research Foundation, a public charity affiliated with Columbia University Medical Center, from which they receive no compensation; the Cardiovascular Research Foundation receives research or educational funding from Boston Scientific, Cordis, Sanofi-Aventis, and Bristol-Myers Squibb.

Figures

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Fig 1 Identification of trials
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Fig 2 Cumulative incidence of death overall and cardiac death and corresponding hazard ratios (95% credibility intervals) for three stent types estimated from network meta-analysis for pairwise comparisons in people with and without diabetes and restricted to trials with dual antiplatelet therapy of at least six months
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Fig 3 Cumulative incidence of myocardial infarction and the composite of death or myocardial infarction and corresponding hazard ratios (95% credibility intervals) for three stent types estimated from network meta-analysis for pairwise comparisons in people with and without diabetes and restricted to trials with dual antiplatelet therapy of at least six months
None
Fig 4 Cumulative incidence of target lesion revascularisation and corresponding hazard ratios (95% credibility intervals) for three stent types estimated from network meta-analysis for pairwise comparisons in people with and without diabetes and restricted to trials with dual antiplatelet therapy of at least six months
See this image and copyright information in PMC

Comment in

References

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