Drug-eluting stents provide better outcomes for patients with acute myocardial infarction than bare metal stents, according to an article in the May 4th issue of the Journal of the American Medical Association.

Previous to the current study, there was a lack of randomized trials to assess the safety and long-term efficacy of sirolimus-eluting stent implantation in patients with acute ST-segment elevation myocardial infarction (STEMI). In Europe, where the trial was conducted, current clinical guidelines recommend the drug abciximab during primary percutaneous coronary intervention.

In the STRATEGY trial, Marco Valgimigli, MD, and colleagues compared angiographic and clinical outcomes for the treatments of high-dose tirofiban plus sirolimus-eluting stenting versus pretreatment with abciximab plus bare-metal stenting. The trial included 175 patients who presented to a single referral center in Italy with STEMI or presumed new left bundle-branch block between March 6, 2003 and April 23, 2004. Patients received either tirofiban plus sirolimus-eluting stenting (n = 87) or abciximab plus bare-metal stenting (n = 88).

The researchers found that 14 of 74 patients (19 percent) in the tirofiban plus sirolimus-eluting stent group and 37 of 74 patients (50 percent) in the abciximab plus bare-metal stent group reached the primary end point at eight months: death, nonfatal myocardial infarction, stroke, or binary restenosis.

Cumulative incidence of death, reinfarction, stroke, or target vessel restenosis was significantly lower in the tirofiban plus sirolimus-eluting stent group (18 percent) compared with the abciximab plus bare-metal stent group (32 percent), predominantly reflecting a reduction in the need for revascularization. Binary restenosis was present in 6 of 67 (9 percent) and 24 of 66 (36 percent) patients in the tirofiban plus sirolimus-eluting stent and abciximab plus bare-metal stent groups, respectively.

"In conclusion, our study provides proof of concept for a new treatment strategy in STEMI that incorporates unrestricted use of sirolimus-eluting stenting but results in no (European market) or only a modest (U.S. market) increase in medical expenditure," the authors wrote.

In an accompanying editorial, Mauricio G. Cohen, MD, and E. Magnus Ohman, MD, discussed the findings of the STRATEGY trial:

"… the STRATEGY trial is an important step in exploring the use of drug-eluting stents in the setting of acute myocardial infarction. The data suggesting that the use of drug-eluting stents in this setting may be superior to the traditional bare-metal stent approach are encouraging. However, the focus should now shift to the long-term prevention of thrombotic complications through appropriate long-term antiplatelet therapies. It is remarkable to see how STEMI management has evolved over the last decade. With use of increasingly sophisticated stent technology, patients with STEMI are now enjoying substantial benefit by virtue of improved reperfusion with primary percutaneous coronary intervention, fewer ischemic complications, and lower rates of long-term restenosis. A goal that seemed very distant only a decade ago appears now to have been achieved."