Choice of stent for AMI patients The University of Tokyo Hospital Jiro Ando, MD
Which Stent we can use in AMI
BMS or DES ?
Drug-Eluting Stents The Concept Stent design and delivery system Drug- Pharmacologic Drug carrier Eluting vehicle agent Stent
The Cypher Sirolimus-Eluting Stent Bx VELOCITY TM Stent • Balloon expandable stainless steel stent • Blend of components: 2 polymers (PEVA + PBMA) and sirolimus in a fixed ratio • Thin uniform coating (~ 10um thick)
CYPHER vs. BMS: TLR Pooled Analyses of 4 RCTs RAVEL, SIRIUS, E-SIRIUS, C-SIRIUS 30% Bare Metal Stent (n=870) CYPHER Stent (n=878) 25% 20% 9.6% (80) p<0.0001 23.9% (205) 15% 10% 5% 0% 0 365 730 1095 1460 1825 Days Number at risk BMS 870 680 659 632 603 518 CYPHER 877 827 797 766 732 645 Kirtane A. TCT 2007. Adapted from Stone GW et al. NEJM 2007;356:998 – 1008
CYPHER vs. BMS: ARC def/prob ST* Pooled Analyses of 4 RCTs RAVEL, SIRIUS, E-SIRIUS, C-SIRIUS 3.0% Bare Metal Stent (n=870) 2.5% CYPHER Stent (n=878) 2.0% 1.5% 2.1% (17) p=0.99 1.0% 2.0% (17) 0.5% 0.0% 0 365 730 1095 1460 1825 Days Number at risk BMS 870 848 834 813 784 683 CYPHER 878 858 835 809 783 694 * ARC def/prob ST counts all ST
Vascular responses in porcine models
BMS or DES ? • BMS Stented region is good Covered with neointima , and we can reduce DAPT in early term . • First generation DES stented region isn’t covered well with neointima , and we continue DAPT in long term. • But BMS result of restenosis rate is higher than DES.
How about Second generarion DES in ACS and DAPT ?
EXAMINATION randomized trial Everolimus-eluting stent vs. Bare-metal stent in ST-segment elevation myocardial infarction
2-year results of the EXAMINATION randomized trial
2-year results of the EXAMINATION randomized trial ― Stent Thrombosis ―
The COMFORTABLE AMI Randomized Trial To compare stents eluting biolimus from a biodegradable polymer with bare-metal stents in primary PCI.
2-year results of the Conformatble AMI
CENTURY II Trial Demonstrate the safety and efficacy of the Ultimaster by comparing with Xience
CENTURY II Trial
CENTURY II – High risk ACS Total population n=1119 BP-SES PP-EES n=562 n=557 Randomization 1:1 Acute Coronary Syndrome n= 264 BP-SES PP-EES n= 126 patients/ n= 138 patients 166 lesions 205 lesions
Clinical outcomes at 12 months P=NS P=NS P=NS P=NS P=NS P=NS P=NS 8% 0.0725 7% Ultimaster Xience 6% 0.0507 0.0476 0.0476 5% 0.0435 4% 0.0362 0.0362 0.0317 0.0317 3% 0.0217 2% 0.0159 0.0159 0.0145 1% 0 0% Cardiac MI Target CD TLR CD TVR TLF TVF death vessel MI TVF: composite of cardiac death, target vessel MI and clinically driven TVR TLF = composite of cardiac death, target vessel MI and clinically driven TLR
Conclusions • 2 nd generation DES is good result for ACS ,and also the risk of thrombotic occulusion is low. • Many of New generation DES will be released , we should check the results of those study and choice good DES for patient.
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