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Paclitaxel-Eluting Stents versus Bare-Metal Stents in Acute Myocardial Infarction

http://content.nejm.org/cgi/content/short/360/19/1946?query=TOC
Volume 360:1946-1959 May 7, 2009 Number 19

ABSTRACT

Background

There is no consensus regarding the safety and efficacy of drug-eluting stents, as compared with bare-metal stents, in patients with ST-segment elevation myocardial infarction who are undergoing primary percutaneous coronary intervention (PCI).

Methods

We randomly assigned, in a 3:1 ratio, 3006 patients presenting with ST-segment elevation myocardial infarction to receive paclitaxel-eluting stents (2257 patients) or otherwise identical bare-metal stents (749 patients). The two primary end points of the study were the 12-month rates of target-lesion revascularization for ischemia (analysis powered for superiority) and a composite safety outcome measure of death, reinfarction, stroke, or stent thrombosis (powered for noninferiority with a 3.0% margin). The major secondary end point was angiographic evidence of restenosis at 13 months.

Results

Patients who received paclitaxel-eluting stents, as compared with those who received bare-metal stents, had significantly lower 12-month rates of ischemia-driven target-lesion revascularization (4.5% vs. 7.5%; hazard ratio, 0.59; 95% confidence interval [CI], 0.43 to 0.83; P=0.002) and target-vessel revascularization (5.8% vs. 8.7%; hazard ratio, 0.65; 95% CI, 0.48 to 0.89; P=0.006), with noninferior rates of the composite safety end point (8.1% vs. 8.0%; hazard ratio, 1.02; 95% CI, 0.76 to 1.36; absolute difference, 0.1 percentage point; 95% CI, –2.1 to 2.4; P=0.01 for noninferiority; P=0.92 for superiority). Patients treated with paclitaxel-eluting stents and those treated with bare-metal stents had similar 12-month rates of death (3.5% and 3.5%, respectively; P=0.98) and stent thrombosis (3.2% and 3.4%, respectively; P=0.77). The 13-month rate of binary restenosis was significantly lower with paclitaxel-eluting stents than with bare-metal stents (10.0% vs. 22.9%; hazard ratio, 0.44; 95% CI, 0.33 to 0.57; P<0.001).

Conclusions

In patients with ST-segment elevation myocardial infarction who were undergoing primary PCI, implantation of paclitaxel-eluting stents, as compared with bare-metal stents, significantly reduced angiographic evidence of restenosis and recurrent ischemia necessitating repeat revascularization procedures. No safety concerns were apparent at 1 year. (ClinicalTrials.gov number, NCT00433966 [ClinicalTrials.gov] .)

Source Information

From Columbia University Medical Center and New York–Presbyterian Hospital and the Cardiovascular Research Foundation (G.W.S., A.J.L., G.D., A.K., H.P., R.M.), and New York–Presbyterian Hospital and Weill Cornell Medical Center (S.C.W.) — all in New York; London School of Hygiene and Tropical Medicine, London (S.J.P.); Mayo Clinic, Rochester, MN (B.J.G.); Charité Campus Benjamin Franklin (B.W.) and Charité Campus Virchow-Klinikum (M.M.) — both in Berlin; Ospedali Riuniti di Bergamo, Bergamo, Italy (G.G.); Medical University, Lodz (J.Z.P.), Jagiellonian University, Krakow (D.D.), and Silesian Medical Academy, Katowice (A.O.) — all in Poland; and LeBauer Cardiovascular Research Foundation and Moses Cone Hospital, Greensboro, NC (B.R.B.).
Gregg W. Stone, M.D., Alexandra J. Lansky, M.D., Stuart J. Pocock, Ph.D., Bernard J. Gersh, M.B., Ch.B., D.Phil., George Dangas, M.D., Ph.D., S. Chiu Wong, M.D., Bernhard Witzenbichler, M.D., Giulio Guagliumi, M.D., Jan Z. Peruga, M.D., Bruce R. Brodie, M.D., Dariusz Dudek, M.D., Martin Möckel, M.D., Andrzej Ochala, M.D., Alison Kellock, B.S., Helen Parise, Sc.D., Roxana Mehran, M.D., for the HORIZONS-AMI Trial Investigators