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Primary percutaneous coronary intervention (PCI) is considered the optimal approach to the management of ST segment elevation myocardial infarction (STEMI) when the procedure is performed expeditiously by an experienced team.1 Drug eluting stents (DES) have been shown to reduce the risks of both restenosis and target vessel revascularisation (TVR) after elective PCI, as compared with bare metal stents (BMS) in a broad range of patients and lesions.2 However, most randomised trials comparing DES to BMS have excluded patients with STEMI because of safety and efficacy concerns in this subgroup. Reports from randomised trials and registries have suggested that DES may be associated with increased rates of late stent thrombosis.3 Thrombus is a major component of coronary artery occlusion in acute myocardial infarction (AMI). Angioplasty with DES in this setting could therefore theoretically increase the rate of stent thrombosis, but data on this issue are conflicting.4 In addition, drug diffusion could be reduced in the presence of massive thrombus, leading to a potential loss of efficacy against neointimal proliferation.
To address these issues, several dedicated randomised controlled trials and registries have assessed the efficacy and safety of DES in the setting of primary PCI for AMI. Most of these studies were performed with sirolimus eluting stents (SES), Cypher (Cordis, Johnson and Johnson), and to a lesser extent with paclitaxel eluting stents (PES), (Taxus, Boston Scientific) and have yielded positive short and long term results in favour of SES and PES. Yet, despite these positive findings, the use of DES during PCI for AMI remains controversial and is still considered ‘off label’ in many countries. The currently available data will be reviewed and put in perspective with clinical practice.
Randomised studies and registries assessing SES or PES in primary PCI for STEMI
To date, 31 studies, 13 randomised trials, and 18 registries have directly compared SES or PES to BMS in …