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Meta-Analysis
. 2013 Nov 8:347:f6625.
doi: 10.1136/bmj.f6625.

Bare metal stents, durable polymer drug eluting stents, and biodegradable polymer drug eluting stents for coronary artery disease: mixed treatment comparison meta-analysis

Sripal Bangalore  1 , Bora Toklu, Nicholas Amoroso, Mario Fusaro, Sunil Kumar, Edward L Hannan, David P Faxon, Frederick Feit
Affiliations
Meta-Analysis

Bare metal stents, durable polymer drug eluting stents, and biodegradable polymer drug eluting stents for coronary artery disease: mixed treatment comparison meta-analysis

Sripal Bangalore et al. BMJ. .

Abstract

Objective: To compare the efficacy and safety of biodegradable polymer drug eluting stents with those of bare metal stents and durable polymer drug eluting stents.

Design: Mixed treatment comparison meta-analysis of 258,544 patient years of follow-up from randomized trials.

Data sources and study selection: PubMed, Embase, and Central were searched for randomized trials comparing any of the Food and Drug Administration approved durable polymer drug eluting stents (sirolimus eluting, paclitaxel eluting, cobalt chromium everolimus eluting, platinum chromium everolimus eluting, zotarolimus eluting-Endeavor, and zotarolimus eluting-Resolute) or biodegradable polymer drug eluting stents, with each other or against bare metal stents.

Outcomes: Long term efficacy (target vessel revascularization, target lesion revascularization) and safety (death, myocardial infarction, stent thrombosis). Landmark analysis at more than one year was evaluated to assess the potential late benefit of biodegradable polymer drug eluting stents.

Results: From 126 randomized trials and 258,544 patient years of follow-up, for long term efficacy (target vessel revascularization), biodegradable polymer drug eluting stents were superior to paclitaxel eluting stents (rate ratio 0.66, 95% credibility interval 0.57 to 0.78) and zotarolimus eluting stent-Endeavor (0.69, 0.56 to 0.84) but not to newer generation durable polymer drug eluting stents (for example: 1.03, 0.89 to 1.21 versus cobalt chromium everolimus eluting stents). Similarly, biodegradable polymer drug eluting stents were superior to paclitaxel eluting stents (rate ratio 0.61, 0.37 to 0.89) but inferior to cobalt chromium everolimus eluting stents (2.04, 1.27 to 3.35) for long term safety (definite stent thrombosis). In the landmark analysis after one year, biodegradable polymer drug eluting stents were superior to sirolimus eluting stents for definite stent thrombosis (rate ratio 0.29, 0.10 to 0.82) but were associated with increased mortality compared with cobalt chromium everolimus eluting stents (1.52, 1.02 to 2.22). Overall, among all stent types, the newer generation durable polymer drug eluting stents (zotarolimus eluting stent-Resolute, cobalt chromium everolimus eluting stents, and platinum chromium everolimus eluting stents) were the most efficacious (lowest target vessel revascularization rate) stents, and cobalt chromium everolimus eluting stents were the safest with significant reductions in definite stent thrombosis (rate ratio 0.35, 0.21 to 0.53), myocardial infarction (0.65, 0.55 to 0.75), and death (0.72, 0.58 to 0.90) compared with bare metal stents.

Conclusions: Biodegradable polymer drug eluting stents are superior to first generation durable polymer drug eluting stents but not to newer generation durable polymer stents in reducing target vessel revascularization. Newer generation durable polymer stents, and especially cobalt chromium everolimus eluting stents, have the best combination of efficacy and safety. The utility of biodegradable polymer stents in the context of excellent clinical outcomes with newer generation durable polymer stents needs to be proven.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; SB has acted as an advisory board participant/consultant for Boehringer Ingelheim, Daiichi Sankyo, Pfizer, Gilead, Abbott, and Abbott-Vascular; FF is a shareholder in Medtronic, Boston Scientific, and Johnson and Johnson; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Flow chart of study selection
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Fig 2 Network of treatment comparisons. Solid line represents direct comparison between stents; dashed line represents indirect comparison between stent types; number represents number of trial providing direct comparison. BMS=bare metal stent; BP-DES=biodegradable polymer stent; CoCr=cobalt chromium; EES=everolimus eluting stent; PES=paclitaxel eluting stent; PtCr=platinum chromium; SES=sirolimus eluting stent; ZES-E=zotarolimus eluting stent-Endeavor; ZES-R=zotarolimus eluting stent-Resolute
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Fig 3 Stent type and risk of target vessel revascularization from network of all trials. CrI=credibility interval; other abbreviations as in fig 1
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Fig 4 Stent type and risk of death from network of all trials. CrI=credibility interval; other abbreviations as in figure 1
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Fig 5 Stent type and risk of myocardial infarction from network of all trials. CrI=credibility interval; other abbreviations as in figure 1
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Fig 6 Stent type and risk of Academic Research Consortium defined definite stent thrombosis from network of all trials. CrI=credibility interval; other abbreviations as in figure 1
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Fig 7 Biodegradable polymer stents in comparison with other stents and risk of target vessel revascularization from network of all trials in landmark analysis beyond one year. CrI=credibility interval; other abbreviations as in figure 1
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Fig 8 Biodegradable polymer stents in comparison with other stents and risk of death from network of all trials in landmark analysis beyond one year. CrI=credibility interval; other abbreviations as in figure 1
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Fig 9 Biodegradable polymer stents in comparison with other stents and risk of myocardial infarction from network of all trials in landmark analysis beyond one year. CrI=credibility interval; other abbreviations as in figure 1
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Fig 10 Biodegradable polymer stents in comparison with other stents and risk of Academic Research Consortium defined definite stent thrombosis from network of all trials in landmark analysis beyond one year. CrI=credibility interval; other abbreviations as in figure 1
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References

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