Everolimus eluting stent vs first generation drug-eluting stent in primary angioplasty: A pooled patient-level meta-analysis of randomized trials

Background Several concerns have emerged about the higher risk of very late stent thrombosis (ST) with first generation drug-eluting stent (DES) especially among STEMI patients. Newer generation DES has demonstrated to reduce ST at mid-term follow-up. Therefore, the aim of the present study is to perform an individual patient's data meta-analysis of trials comparing 1st generation DES vs. 2nd generation DES (everolimus-eluting stent, EES) in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI. Methods We performed a formal search of electronic databases (MEDLINE and CENTRAL) and scientific session presentations from January 2010 to June 2016. We included all completed randomized trials comparing 1st vs. EES for patient presenting with STEMI. Results Individual patients data were obtained from 3 trials, including a total of 1581 patients (686 or 43.4% randomized to 1st generation DES and 895 or 56.4% randomized to EES). At long-term follow-up (1584 ± 588 days), EES did not significantly reduce mortality (7.8.% vs 11.7%, HR [95%CI] = 0.77 [0.52, 1.13], p = 0.18, pheterogeneity = 0.93), cardiac mortality (6.2% vs 7.6%, HR [95%CI] = 0.90 [0.56, 1.44], p = 0.65, pheterogeneity = 0.85), and reinfarction (8.1% versus 11.2%, respectively; HR [95%CI] = 0.74 [0.51, 1.07], p = 0.11, pheterogeneity = 0.52). However, EES significantly reduced the occurrence of ST (3.4% versus 6.1% respectively, HR [95%CI] = 0.56 [0.32, 0.97], p = 0.04, pheterogeneity = 0.42) and target vessel revascularization (TVR) (14.2% versus 20.1%; HR [95%CI] = 0.63 [0.42, 0.96], p = 0.03, pheterogeneity = 0.55). Landmark analysis showed more consistent benefits in ST with EES within 1 year, whereas benefits in TVR were mostly observed later than 1 year. Conclusions The present pooled patient-level meta-analysis demonstrates that among STEMI patients undergoing primary PCI, EES as compared to 1st generation DES is associated with a significant reduction in ST and TVR at long-term follow-up.