Dr. Daniel B. Mark
The late occurrence of stent thromboses between 12 and 30 months in both study arms “really makes us think of this issue of DAPT in a different way than we have in the past,” added Dr. Mark, professor of medicine at Duke University and director of outcomes research at the Duke Clinical Research Institute in Durham, N.C.
He observed that “a perfect storm” of observational evidence arose beginning in 2006 which convinced physicians that BMS were safer – wrongly, as it now turns out.
The conventional wisdom was that BMS had a restenosis problem seen as “a benign nuisance requiring repeat revascularization procedures but having no discernible effect on death or MI,” Dr. Marks said, “while the DES were extremely effective at reducing restenosis but had this stent thrombosis problem” that was viewed in hyperbolic terms in the literature. The DAPT trial has gone a long way towards correcting those misperceptions, he said.
He wondered, however, just how confident Dr. Kereiakes is in the validity of his propensity matching.
“The matching was based on 55 different variables,” Dr. Kereiakes replied. “With all the limitations inherent in propensity-matched analysis, I think this is about as good as it gets.”
Dr. Mark noted that while cardiologists ponder the fine points between DES and BMS, it’s important not to lose sight of the big picture as highlighted in a recent study by Dr. Mark A. Hlatky of Stanford (Calif.) University and coinvestigators. Their analysis of Medicare beneficiaries who underwent either multivessel coronary artery bypass surgery or multivessel percutaneous coronary intervention concluded that the introduction of DES didn’t alter the comparative effectiveness of CABG and PCI. The 5-year survival rate following CABG has been about 10% better than with PCI both in the pre-DES era of BMS and in the DES era. Moreover, the 5-year rate of freedom from MI has been about 18% better with multivessel CABG than multivessel PCI in both stent platform eras (Am. Heart J. 2014;169:149-54).
The DAPT study was supported by more than half a dozen pharmaceutical and medical device companies as well as the U.S. Department of Health and Human Services. Dr. Kereiakes reported receiving payments as an advisor to Boston Scientific and Abbott Vascular. Dr. Marks reported receiving research grants from the National Institutes of Health and serving as a consultant to Somahlution, Milestone, Medtronic, and CardioDx.