Dr. Sripal Bangalore (New York University, NY) and colleagues analyzed 42 trials comparing four major types of DES — sirolimus, paclitaxel, everolimus, and zotarolimus — with each other and with bare-metal stents for the treatment of de novo coronary lesions in patients with diabetes. The results in this diabetic subgroup, largely mirror that of this group’s overall meta-analysis of 76 randomized controlled trials with 117,762 patient-years of follow-up, published in Circulation.
Overall, the analysis covers a total of 22,844 patient-years of follow-up. All of the studies selected for this meta-analysis had at least 50 diabetic patients.
Although the analysis shows that all four of the DES evaluated reduced target vessel revascularization compared with bare-metal stents (37% vs. 69%) without any offsetting safety concerns, the DES did not all perform equally as well. Based on all of the comparisons, the authors calculate there is an 87% probability that everolimus-eluting stents are the most efficacious compared with all others and a 62% chance that everolimus-eluting stents are the least likely to develop any stent thrombosis.
Bangalore et al note that a 2007 pooled patient-level meta-analysis of sirolimus-eluting-stent trials suggested an increased risk of mortality with sirolimus-eluting stents compared with bare-metal stents in the subgroup with diabetes. But that study included only 428 patients with diabetes, and the study by Bangalore et al found no such safety concerns in a sample 25 times as large.
This analysis found that Endeavor (Medtronic) zotarolimus-eluting stents were associated with a higher rate of repeat revascularization than either sirolimus-eluting stents or everolimus-eluting stents and a higher rate of MI than sirolimus-eluting stents, paclitaxel-eluting stents, or everolimus-eluting stents. However, the authors point out that the data on Resolute zotarolimus-eluting stents are still limited, and the analysis could include only two published trials of these stents, TWENTE and RESOLUTE All-Comers. "The credibility interval around the estimates for zotarolimus-eluting stents were wide, suggesting less precision and confidence in the estimates, probably because of limited published data on the use of zotarolimus-eluting stents in patients with diabetes," Bangalore et al explain. "This analysis on the zotarolimus-eluting Resolute stent should therefore be viewed as highly exploratory."
Bangalore S, Kumar S, Fusaro M, et al. Outcomes with various drug eluting or bare metal stents in patients with diabetes mellitus: mixed treatment comparison analysis of 22 844 patient years of follow-up from randomized trials. BMJ 2012; DOI:10.1136/bmj.e5170. Available at: http://www.bmj.com.