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Meta-Analysis
. 2014 Nov 4:349:g6427.
doi: 10.1136/bmj.g6427.

Effects of cobalt-chromium everolimus eluting stents or bare metal stent on fatal and non-fatal cardiovascular events: patient level meta-analysis

Marco Valgimigli  1 , Manel Sabaté  2 , Christoph Kaiser  3 , Salvatore Brugaletta  2 , Jose Maria de la Torre Hernandez  4 , Soeren Galatius  5 , Angel Cequier  6 , Franz Eberli  7 , Adam de Belder  8 , Patrick W Serruys  9 , Giuseppe Ferrante  10
Affiliations
Meta-Analysis

Effects of cobalt-chromium everolimus eluting stents or bare metal stent on fatal and non-fatal cardiovascular events: patient level meta-analysis

Marco Valgimigli et al. BMJ. .

Abstract

Objectives: To examine the safety and effectiveness of cobalt-chromium everolimus eluting stents compared with bare metal stents.

Design: Individual patient data meta-analysis of randomised controlled trials. Cox proportional regression models stratified by trial, containing random effects, were used to assess the impact of stent type on outcomes. Hazard ratios with 95% confidence interval for outcomes were reported.

Data sources and study selection: Medline, Embase, the Cochrane Central Register of Controlled Trials. Randomised controlled trials that compared cobalt-chromium everolimus eluting stents with bare metal stents were selected. The principal investigators whose trials met the inclusion criteria provided data for individual patients.

Primary outcomes: The primary outcome was cardiac mortality. Secondary endpoints were myocardial infarction, definite stent thrombosis, definite or probable stent thrombosis, target vessel revascularisation, and all cause death.

Results: The search yielded five randomised controlled trials, comprising 4896 participants. Compared with patients receiving bare metal stents, participants receiving cobalt-chromium everolimus eluting stents had a significant reduction of cardiac mortality (hazard ratio 0.67, 95% confidence interval 0.49 to 0.91; P=0.01), myocardial infarction (0.71, 0.55 to 0.92; P=0.01), definite stent thrombosis (0.41, 0.22 to 0.76; P=0.005), definite or probable stent thrombosis (0.48, 0.31 to 0.73; P<0.001), and target vessel revascularisation (0.29, 0.20 to 0.41; P<0.001) at a median follow-up of 720 days. There was no significant difference in all cause death between groups (0.83, 0.65 to 1.06; P=0.14). Findings remained unchanged at multivariable regression after adjustment for the acuity of clinical syndrome (for instance, acute coronary syndrome v stable coronary artery disease), diabetes mellitus, female sex, use of glycoprotein IIb/IIIa inhibitors, and up to one year v longer duration treatment with dual antiplatelets.

Conclusions: This meta-analysis offers evidence that compared with bare metal stents the use of cobalt-chromium everolimus eluting stents improves global cardiovascular outcomes including cardiac survival, myocardial infarction, and overall stent thrombosis.

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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 and declare that MV has received honorariums for lectures/advisory board from Abbott Vascular and that MS, AC, and SG have received honorariums for lectures/advisory board and research grant from Abbott Vascular.

Figures

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Fig 1 Flow diagram of literature search for studies included in meta-analysis
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Fig 2 Risk of bias summary reporting each risk of bias item for each included study
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Fig 3 Cumulative hazard for cardiac death and forest plot with point estimates and 95% confidence intervals for each included study and pooled estimate from simple Cox regression model stratified by trial with random effects. Co-Cr EES=cobalt-chromium everolimus eluting; BMS=bare metal stent
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Fig 4 Cumulative incidence curve for myocardial infarction and forest plot with point estimates and 95% confidence intervals for each included study and pooled estimate from simple Cox regression model stratified by trial with random effects. Co-Cr EES=cobalt-chromium everolimus eluting; BMS=bare metal stent
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Fig 5 Cumulative incidence curve for fatal myocardial infarction and forest plot with point estimates and 95% confidence interval for each included study and pooled estimate from simple Cox regression model stratified by trial with random effects. Co-Cr EES=cobalt-chromium everolimus eluting; BMS=bare metal stent
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Fig 6 Cumulative incidence curve for definite stent thrombosis and forest plot with point estimates and 95% confidence interval for each included study and pooled estimate from simple Cox regression model stratified by trial with random effects. Co-Cr EES=cobalt-chromium everolimus eluting; BMS=bare metal stent
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Fig 7 Cumulative incidence curve for definite or probable stent thrombosis and forest plot with point estimates and 95% confidence interval for each included study and pooled estimate from simple Cox regression model stratified by trial with random effects. Co-Cr EES=cobalt-chromium everolimus eluting; BMS=bare metal stent
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Fig 8 Cumulative incidence curve for target vessel revascularisation and forest plot with point estimates and 95% confidence interval for each included study and pooled estimate from simple Cox regression model stratified by trial with random effects. Co-Cr EES=cobalt-chromium everolimus eluting; BMS=bare metal stent
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Fig 9 Subgroup analyses for treatment effect, with P value for interaction. IIb/IIIa=glycoprotein IIb/IIIa inhibitors
See this image and copyright information in PMC

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