Drug eluting and bare metal stents in people with and without diabetes: collaborative network meta-analysis

doi:10.1136/bmj.a1331

Published 31 August 2008, doi:10.1136/bmj.a1331
Cite this as: BMJ 2008;337:a1331

Research

Drug eluting and bare metal stents in people with and without diabetes: collaborative network meta-analysis

Christoph Stettler, senior research fellow¹^,2^,3, Sabin Allemann, research fellow¹^,2, Simon Wandel, research fellow¹, Adnan Kastrati, professor of cardiology⁴, Marie Claude Morice, professor of cardiology⁵, Albert Schömig, professor of medicine⁴, Matthias E Pfisterer, professor of cardiology⁶, Gregg W Stone, professor of medicine⁷, Martin B Leon, professor of medicine ⁷, José Suárez de Lezo, professor of cardiology⁸, Jean-Jacques Goy, professor of interventional cardiology⁹, Seung-Jung Park, professor of cardiology¹⁰, Manel Sabaté, associate professor of cardiology¹¹, Maarten J Suttorp, head of department ¹², Henning Kelbaek, associate professor of cardiology ¹³, Christian Spaulding, professor of cardiology ¹⁴, Maurizio Menichelli, interventional cardiologist¹⁵, Paul Vermeersch, interventional cardiologist¹⁶, Maurits T Dirksen, training fellow in cardiology¹⁷, Pavel Cervinka, cardiologist¹⁸, Marco De Carlo, vice director¹⁹, Andrejs Erglis, associate professor of cardiology²⁰, Tania Chechi, interventional cardiologist²¹, Paolo Ortolani, interventional cardiologist²², Martin J Schalij, professor of cardiology²³, Peter Diem, head of division ², Bernhard Meier, professor of cardiology²⁴, Stephan Windecker, head of invasive cardiology ²⁴^,25, Peter Jüni, head of division ¹^,25

¹ Institute of Social and Preventive Medicine, University of Bern, 3012 Bern, Switzerland, ² Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital, Bern, Switzerland, ³ International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, ⁴ Deutsches Herzzentrum, Technische Universität, Munich, Germany, ⁵ Institut Hospitalier Jacques Cartier, Massy, France, ⁶ Division of Cardiology, University Hospital, Basel, Switzerland, ⁷ Columbia University Medical Center, New York, USA, ⁸ Servicio de Cardiología, Hospital Universitario Reina Sofía, Cordoba, Spain, ⁹ Service of Cardiology, Clinique Cecil, Lausanne, Switzerland, ¹⁰ Department of Medicine, ASAN Medical Center, Seoul, Korea, ¹¹ Department of Interventional Cardiology, Hospital de San Pau, Barcelona, Spain, ¹² Department of Interventional Cardiology, St Antonius Hospital, Nieuwegein, Netherlands, ¹³ Cardiac Catheterisation Laboratory, Rigshospitalet, Copenhagen, Denmark, ¹⁴ Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris Descartes University, and INSERM U 780, Paris, France, ¹⁵ San Camillo Hospital, Rome, Italy, ¹⁶ Antwerp Cardiovascular Institute Middelheim, Antwerp, Belgium, ¹⁷ Amsterdam Department of Interventional Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands, ¹⁸ Division of Cardiology, Masaryk Hospital, Ústí nad Labem, Czech Republic, ¹⁹ Cardiothoracic and Vascular Department, University of Pisa, Italy, ²⁰ University of Latvia, Institute of Cardiology, Riga, Latvia, ²¹ Cardiologia e Cardiologia Invasiva 2–AOU-Careggi, Florence, Italy, ²² Institute of Cardiology, S Orsola-Malpighi Hospital, University of Bologna, Italy, ²³ Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands, ²⁴ Department of Cardiology, Bern University Hospital, Bern, Switzerland, ²⁵ CTU Bern, Bern University Hospital, 3010 Bern, Switzerland

Correspondence to: P Jüni juni{at}ispm.unibe.ch

Objective To compare the effectiveness and safety of three typesof stents (sirolimus eluting, paclitaxel eluting, and bare metal)in people with and without diabetes mellitus.

Design Collaborative network meta-analysis.

Data sources Electronic databases (Medline, Embase, the CochraneCentral Register of Controlled Trials), relevant websites, referencelists, conference abstracts, reviews, book chapters, and proceedingsof advisory panels for the US Food and Drug Administration.Manufacturers and trialists provided additional data.

Review methods Network meta-analysis with a mixed treatmentcomparison method to combine direct within trial comparisonsbetween stents with indirect evidence from other trials whilemaintaining randomisation. Overall mortality was the primarysafety end point, target lesion revascularisation the effectivenessend point.

Results 35 trials in 3852 people with diabetes and 10 947 peoplewithout diabetes contributed to the analyses. Inconsistencyof the network was substantial for overall mortality in peoplewith diabetes and seemed to be related to the duration of dualantiplatelet therapy (P value for interaction 0.02). Restrictingthe analysis to trials with a duration of dual antiplatelettherapy of six months or more, inconsistency was reduced considerablyand hazard ratios for overall mortality were near one for allcomparisons in people with diabetes: sirolimus eluting stentscompared with bare metal stents 0.88 (95% credibility interval0.55 to 1.30), paclitaxel eluting stents compared with baremetal stents 0.91 (0.60 to 1.38), and sirolimus eluting stentscompared with paclitaxel eluting stents 0.95 (0.63 to 1.43).In people without diabetes, hazard ratios were unaffected bythe restriction. Both drug eluting stents were associated witha decrease in revascularisation rates compared with bare metalstents in people both with and without diabetes.

Conclusion In trials that specified a duration of dual antiplatelettherapy of six months or more after stent implantation, drugeluting stents seemed safe and effective in people both withand without diabetes.

Add to CiteULike CiteULike Add to Complore Complore Add to Connotea Connotea Add to Del.icio.us Del.icio.us Add to Digg Digg Add to Reddit Reddit Add to StumbleUpon StumbleUpon Add to Technorati Technorati What's this?

Relevant Articles

Drug eluting stents in patients with diabetes: Pierfrancesco Agostoni and Frank Van den Branden
BMJ 2008 337: a1359. [Extract] [Full Text]

Simultaneous comparison of multiple treatments: combining direct and indirect evidence: Deborah M Caldwell, A E Ades, and J P T Higgins
BMJ 2005 331: 897-900. [Extract] [Full Text] [PDF]

Systematic reviews in health care: Assessing the quality of controlled clinical trials: Peter Jüni, Douglas G Altman, and Matthias Egger
BMJ 2001 323: 42-46. [Extract] [Full Text] [PDF]

Systematic Review: Why sources of heterogeneity in meta-analysis should be investigated: S G Thompson
BMJ 1994 309: 1351-1355. [Extract] [Full Text]

This article has been cited by other articles:

Barlis, P., Regar, E., Serruys, P. W., Dimopoulos, K., van der Giessen, W. J., van Geuns, R.-J. M., Ferrante, G., Wandel, S., Windecker, S., van Es, G.-A., Eerdmans, P., Juni, P., di Mario, C. (2009). An optical coherence tomography study of a biodegradable vs. durable polymer-coated limus-eluting stent: a LEADERS trial sub-study. Eur Heart J 0: ehp480v1-ehp480 [Abstract] [Full text]
Ioannidis, J. P.A. (2009). Integration of evidence from multiple meta-analyses: a primer on umbrella reviews, treatment networks and multiple treatments meta-analyses. CMAJ 181: 488-493 [Full text]
Kim, W.-J., Park, D.-W., Yun, S.-C., Lee, J.-Y., Lee, S.-W., Kim, Y.-H., Lee, C. W., Park, S.-W., Park, S.-J. (2009). Impact of Diabetes Mellitus on the Treatment Effect of Percutaneous or Surgical Revascularization for Patients With Unprotected Left Main Coronary Artery Disease: A Subgroup Analysis of the MAIN-COMPARE Study. J Am Coll Cardiol Intv 2: 956-963 [Abstract] [Full text]
Kirtane, A. J., Patel, R., O'Shaughnessy, C., Overlie, P., McLaurin, B., Solomon, S., Mauri, L., Fitzgerald, P., Popma, J. J., Kandzari, D. E., Leon, M. B. (2009). Clinical and Angiographic Outcomes in Diabetics From the ENDEAVOR IV Trial: Randomized Comparison of Zotarolimus- and Paclitaxel-Eluting Stents in Patients With Coronary Artery Disease. J Am Coll Cardiol Intv 2: 967-976 [Abstract] [Full text]
Caixeta, A., Leon, M. B., Lansky, A. J., Nikolsky, E., Aoki, J., Moses, J. W., Schofer, J., Morice, M.-C., Schampaert, E., Kirtane, A. J., Popma, J. J., Parise, H., Fahy, M., Mehran, R. (2009). 5-year clinical outcomes after sirolimus-eluting stent implantation insights from a patient-level pooled analysis of 4 randomized trials comparing sirolimus-eluting stents with bare-metal stents.. J Am Coll Cardiol 54: 894-902 [Abstract] [Full text]
Costa, J. R. Jr, Abizaid, A., Costa, R., Feres, F., Tanajura, L. F., Abizaid, A., Maldonado, G., Staico, R., Siqueira, D., Sousa, A. G.M.R., Bonan, R., Sousa, J. E. (2009). 1-Year Results of the Hydroxyapatite Polymer-Free Sirolimus-Eluting Stent for the Treatment of Single De Novo Coronary Lesions: The VESTASYNC I Trial. J Am Coll Cardiol Intv 2: 422-427 [Abstract] [Full text]
Windecker, S., Juni, P. (2009). The Drug-Eluting Stent Saga. Circulation 119: 653-656 [Full text]
Garg, P., Normand, S.-L. T., Silbaugh, T. S., Wolf, R. E., Zelevinsky, K., Lovett, A., Varma, M. R., Zhou, Z., Mauri, L. (2008). Drug-Eluting or Bare-Metal Stenting in Patients With Diabetes Mellitus: Results From the Massachusetts Data Analysis Center Registry. Circulation 118: 2277-2285 [Abstract] [Full text]
Agostoni, P., Branden, F. V. d. (2008). Drug eluting stents in patients with diabetes. BMJ 337: a1359-a1359 [Full text]