Real world PCI: as good as in published trials, but will increased DES usage provide even better results?

EDITORIAL

Seattle Cardiology and Swedish Medical Center, Seattle, WA, USA

Correspondence

In this issue of the Revista Brasileira de Cardiologia Invasiva, Abelin et al.¹ present their collective experience with percutaneous coronary intervention (PCI) from a single center over a 12 year period. This effort is commendable as it provides a snapshot of real-world practice not subject to inclusion or exclusion criteria or selection bias that invariably occurs with prospective clinical trials and multicenter registries. Two thirds of the patient's treated had complex type B2/C lesions and more than half of the patients presented with unstable angina or acute myocardial infarction. In this unselected consecutive series, the procedural success was a remarkable 97.1% with early stent thrombosis rate of only 0.39%. The 30-day outcomes are in line or better than the results in the most recently published large-scale multicenter observational registries of coronary PCI^2,3. In a random sample of 1610 patients with one-year clinical follow-up, the need for repeat target vessel revascularization was 15.7%. This is the one finding that stands out as a relatively need for repeat target vessel revascularization, but is explained by the high use a bare metal stents in Brazil. Although the proportion of patients receiving bare metal versus drug-eluting stents is not reported in a series, it is typically between 10 and 20% in Brazil, and this relatively low percentage use of drug eluting stents likely explains the relatively high need for repeat revascularization in this population.

The true value of this database is that it validates the findings of the previously published multicenter registries. Too often the results from observational registries are criticized for not truly representing real-world practice even though they are intended to do so because of factors such as site and/or operator selection, inclusion exclusion criteria and lack of proper follow-up. The present unselected database reports clinical outcomes equivalent to most recently reported multicenter registries of coronary PCI. It also points out the potential benefits of more broad-based use of drug eluting stents in Brazil, which we know that interventionalists in Brazil are well aware of, but for economic reasons, are faced with challenging decisions on a daily basis because of the high-cost of the newer technologies. A concerted appeal needs to be made to device manufacturers distributors and payers to address this problem so that a larger proportion of patients in Brazil can benefit from drug eluting stents today, and other new technologies that are to come in the future.

CONFLICT OF INTEREST

The author is a consultant to Abbott Vascular, Boston Scientific Corp., Cordis Corp. and Medtronic Inc.

REFERENCES

• 1. Abelin AP, Quadros AS, Zanettini MT, Leboute FC, Yordi LM, Cardoso CR, et al. Doze anos de experiência com implante de stents coronários em 5.284 pacientes. Rev Bras Cardiol Invas. 2009;17(3):346-51.
• 2. Douglas PS, Brennan JM, Anstrom KJ, Sedrakyan A, Eisenstein EL, Haque G, et al. Clinical effectiveness of coronary stents in elderly persons: results from 262,700 Medicare patients in the American College of Cardiology-National Cardiovascular Data Registry. J Am Coll Cardiol. 2009;53(18):1629-41.
• 3. Ko DT, Chiu M, Guo H, Austin PC, Goeree R, Cohen E, et al. Safety and effectiveness of drug-eluting and bare-metal stents for patients with off- and on-label indications. J Am Coll Cardiol. 2009;53(19):1773-82.

Real world PCI: as good as in published trials, but will increased DES usage provide even better results?

Robert M. Bersin

Publication Dates

• Publication in this collection
  10 Aug 2012
• Date of issue
  Sept 2009