Selective Use of Drug Eluting Stents in Management of Coronary Heart Disease While Maintaining a Low Target Vessel Revascularisation Rate

Background: Drug-eluting stents (DES) deployment during percutaneous coronary intervention (PCI) have reduced target-vessel revasularisation rate (TVR). Selective criteria for use of DES in patients at high risk of restenosis may achieve low TVR rate and minimise the concern about late stent thrombosis after cessation of dual anti-platelet therapy following DES. Methods and Results: Clinical outcomes were examined in 2118 consecutive patients (mean age 63 ± 12 years, 25% female, 21% diabetics) who underwent PCI between October 2003 and October 2006. Clinical indications were: ST-elevation myocardial infarction (30%), non-ST elevation acute coronary syndromes (44%), and stable-coronary heart disease (26%). Among those who received stents (98%), 29% received ≥1 DES and 71% received BMS. Selective DES-criteria were: left main stenosis; ostial lesions of major epicardial arteries; proximal-LAD lesions; lesions ≥20 mm in length with vessel diameter ≤3.0 mm; lesions in vessels ≤2.5 mm; diabetics with vessel(s) ≤3.0 mm; and in-stent restenosis. Among those who received DES, 91% met the criteria. Baseline clinical and angiographic characteristics comparing BMS with DES were similar between groups except for diabetes, lesion length, stent diameter, proximal-LAD and left main lesions. At one year, patients receiving BMS compared to DES, the TVR rates were 6.1% vs 5.0% (p = 0.346); re-infarction was 2.1% vs 2.8% (p = 0.369), definite stent thrombosis were 0.6% vs 2.1% (p = 0.04) and mortality rates were 4.5% vs 4.0% (p = 0.612). TVR with BMS and DES were 9.7% and 5.1% for diabetics; and 5.3% and 4.9% for non-diabetics, respectively. Conclusion: It is possible to use selective criteria for DES while maintaining low TVR rates. TVR rate among non-diabetics with BMS was low following these criteria. Comparison of selective versus routine DES use should be considered in randomized clinical trial.