{"id":3650,"date":"2010-10-06T15:01:08","date_gmt":"2010-10-06T19:01:08","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?p=3650"},"modified":"2011-07-19T17:44:15","modified_gmt":"2011-07-19T21:44:15","slug":"the-skinny-on-drug-eluting-stents-des","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2010\/10\/06\/the-skinny-on-drug-eluting-stents-des\/","title":{"rendered":"The Skinny on Drug-Eluting Stents (DES)"},"content":{"rendered":"

(“All we want are the facts, ma\u2019am.”<\/em> \u2013Joe Friday, Dragnet)<\/p>\n

Having trouble keeping up with DES and the recent stent studies? Want a brief tutorial? To learn the top six things every cardiologist should know about DES, read on\u2026<\/em><\/span><\/p>\n

1. What they do.<\/strong> DES are superior to both bare-metal stents and angioplasty in reducing the incidence of clinical restenosis and the need for reintervention\u00a0after PCI. Clinical restenosis occurs in 30% to 50% of patients after angioplasty, in 20% to 30% after bare-metal stent implantation, and in about 10% after DES implantation.<\/p>\n

Compared with bare-metal stents, DES confer an increased risk for stent thrombosis months (and years) after placement. Therefore, patients who receive DES are placed on dual antiplatelet therapy for at least a year, which increases their risk for a bleeding complication.<\/p>\n

2. What they don\u2019t do.<\/strong> DES do not reduce the risk for death or MI in patients with stable ischemic heart disease. This is a commonly held misperception (among patients and physicians). Sorry to burst this bubble.<\/em><\/p>\n

3. First-generation stents.<\/strong> Three first-generation DES are available in the U.S.: the sirolimus-eluting CYPHER stent (Cordis), the paclitaxel-eluting TAXUS stent (Boston Scientific) and the zotarolimus-eluting ENDEAVOR stent (Medtronic). Outcomes after sirolimus- and paclitaxel-eluting stent implantation appear to be similar; however, the zotarolimus-eluting stent appears to be less effective (higher all cause-mortality, MI, and target-lesion restenosis [TLR] at 18 months than the sirolimus-eluting stent in the SORT OUT III study). Hard to justify using the zotarolimus-eluting stent.<\/em><\/p>\n

4. Second-generation stents. <\/strong>Second-generation DES are designed to improve stent deployment, safety, and efficacy by altering the composition and thickness of the metal struts, the copolymer, and\/or the antiproliferative drug. Second-generation DES release everolimus, a semisynthetic sirolimus analogue, from a thin coating of a biocompatible fluoropolymer on a flexible cobalt\u2013chromium stent frame with thin struts.<\/p>\n

<\/a>\"\"<\/p>\n

Figure 1. Scanning Electron Micrographs of a Paclitaxel-Eluting Stent and an Everolimus-Eluting Stent.<\/strong> Shown are scanning electron micrographs of a cross-section of a paclitaxel-eluting stent strut (TAXUS Express, Boston Scientific) (Panel A) and an everolimus-eluting stent strut (XIENCE V, Abbott) (Panel B). As compared with the everolimus-eluting stent, the paclitaxel-eluting stent has a thicker strut and a thicker polymer coating (arrow). Reprinted with permission from Doostzadeh et al. Recent progress in percutaneous coronary intervention: Evolution of the drug-eluting stents, focus on the XIENCE V drug-eluting stent.<\/em> Coron Artery Dis 2010; 21:46-56.<\/em><\/span><\/p>\n

____________________________________________________________<\/em><\/span><\/p>\n

Two everolimus-eluting stents are currently available in the U.S.: the Xience V (Abbott) and the Promus (Boston-Scientific “private label”). Don\u2019t be fooled. The Promus stent\u00a0is actually the Xience V stent from Abbott (i.e., like bottling the same wine under 2 different labels\u2026vive la diff\u00e9rence!<\/em>)<\/p>\n

Why sell 2 second-generation stents that are identical?<\/em> DES is big business, with a world market of approximately $5 billion annually and over 2 million stents implanted already.\u00a0Not surprisingly, therefore,\u00a0both companies want a share of the market.<\/p>\n

The second-generation stents cost about $300 more than the first-generation stents.<\/p>\n

5. Stent Wars: Who\u2019s Winning?<\/strong> In two studies (COMPARE<\/a> and SPIRIT IV<\/a>) with 2-year follow-up, the second-generation everolimus-eluting stent was superior to the first generation paclitaxel-eluting stent, with fewer stent “failures” (i.e., composite cardiac death, MI, TLR and stent thrombosis).<\/p>\n

In two studies (SORT OUT IV<\/a> and ISAR\u00a04<\/a>) with 9 and 24 months of follow-up, the second-generation everolimus-eluting stent was noninferior to the first-generation sirolimus-eluting stent, with a trend towards less restenosis with the everolimus-eluting device after longer follow-up.<\/p>\n

6. The Bottom Line.<\/strong> Studies have shown that the everolimus-eluting stent is comparable to the less-expensive sirolimus-eluting stent (although longer follow-up and additional studies are needed to confirm this) and superior to the paclitaxel-eluting stent.<\/p>\n

In patients with diabetes, who comprise 20% to 30% of patients undergoing PCI, the second-generation stents do not appear to be more effective than the first-generation (less expensive) stents.<\/p>\n","protected":false},"excerpt":{"rendered":"

(“All we want are the facts, ma\u2019am.” \u2013Joe Friday, Dragnet) Having trouble keeping up with DES and the recent stent studies? Want a brief tutorial? To learn the top six things every cardiologist should know about DES, read on\u2026 1. What they do. DES are superior to both bare-metal stents and angioplasty in reducing the […]<\/p>\n","protected":false},"author":214,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,9],"tags":[331,301,437],"class_list":["post-3650","post","type-post","status-publish","format-standard","hentry","category-general","category-interventional-cardiology","tag-des","tag-pci","tag-stents"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/3650","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/214"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=3650"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/3650\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=3650"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=3650"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=3650"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}