Drug-Eluting Stents Vs Bare-Metal Stents in Older Adults

By Will Boggs MD

NEW YORK (Reuters Health) - Elderly patients with coronary artery disease (CAD) have better outcomes with drug-eluting stents (DES) than bare-metal stents (BMS), with similar durations of double antiplatelet therapy (DAPT), according to results from the SENIOR trial.

"You can safely and effectively treat elderly patients with coronary artery disease with the latest generation thin-strut DES and reduced, short, BMS-like DAPT,” Dr. Olivier Varenne from Hopital Cochin, Assistance Publique-Hopitaux de Paris, in France, told Reuters Health by email. “You will then avoid unnecessary reinterventions and repeat percutaneous coronary interventions (PCIs), without additional undue bleeding.”

Elderly patients commonly receive BMS during PCI to minimize the risk of bleeding complications associated with longer-duration antiplatelet therapy, which DES require.

Dr. Varenne and colleagues from 44 centers in nine countries compared outcomes between the latest generations of DES and BMS in 1,200 PCI patients age 75 or older (mean, 81.4) with a similar planned duration of DAPT.

The findings were published online November 1 in The Lancet and presented at the Transcatheter Cardiovascular Therapeutics (TCT) 2017 scientific symposium in Denver, Colorado.

At 1 year, the primary composite endpoint - all-cause mortality, myocardial infarction (MI), ischemia-driven target-lesion revascularization (IDTLR), or stroke - had occurred in 12% of DES patients and 16% of BMS patients (P=0.02), according to the November 1 Lancet online report.

Individual rates of all-cause mortality, cardiac death, MI, and stroke at 1 year did not differ between the groups, but IDTLR was significantly more common in the BMS group than the DES group.

Results were consistent in the per-protocol analysis (primary endpoint, 11% with DES vs. 16% with BMS; P=0.008), and treatment effects were consistent across predefined subgroups.

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Bleeding complications and times to DAPT discontinuation did not differ significantly between the two treatment arms.

"The findings of this study apply to a specific DES platform and cannot, therefore, be extrapolated to other bioabsorbable or durable polymer DES platforms," the researchers caution.

“The SENIOR trial did not include very frail patients and, therefore, no definite answer could be made for this specific population,” Dr. Varenne said. “Cost-effectiveness and 2-year results analyses are ongoing.”

“More than a third (37%) of patients in SENIOR are in the young cohort of 75–79 years, a group by modern standards considered not elderly,” write Dr. Robert T. Gerber and Dr. Anthony H. Gershlick from Conquest Hospital, East Sussex, UK, in a related commentary. “This factor then poses the question as to whether or not this trial is sufficient in its own right to recommend informal (i.e., interventionists alter practice) or formal change in guidelines.”

“We feel it is not, as it is a single trial with only two variables and a small number of patients with a median age of 81 years,” they conclude. “However, what it might do is suggest that if an elderly patient at high bleeding risk is having PCI, then a DES might now be considered with the knowledge that a shorter duration of DAPT may not lead to more ischemic events and will probably reduce the risk of bleeding.”

Boston Scientific funded the trial and had various relationships with several of the authors of this report, including Dr. Varenne.

SOURCES: https://bit.ly/2hpwxCq and https://bit.ly/2yQmBte

Lancet 2017.

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