FROM THE EDITOR
JOURNAL COMMENTARY
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What do you see as some of the more promising trends for
interventional cardiologists?
and 12 months after DES implantation. Interestingly in that study any
TIMI bleeding was lower in the dual antiplatelet therapy group and there
was no difference in other outcome events such as target vessel revascularization myocardial infarction or stent thrombosis. ISAR-TRIPLE4 investigated triple therapy in patients needing oral anticoagulation after stenting
and did not compare BMS with DES. The only semi-comparable trial is the
LEADERS-FREE trial5 which compared a novel polymer-free drug coated
stent using umirolimus to a similar BMS in patients with high bleeding
risk who had PCI. In that study all patients also had only one month of
DAPT. The primary safety end point (a composite of cardiac death, myocardial infarction, or stent thrombosis) occurred in 9.4% of patients in the
DES group and 12.9% in the BMS group, which proved significant for noninferiority. Target lesion revascularization however was needed on only
5.9% of DES patients compared to 9.8% in the BMS group (p.001). If we
assume that the drug used was not responsible for driving endpoints, the
LEADERS-FREE conclusions are similar to the ZEUS trial conclusions—a
DES was superior to a BMS with respect to safety and efficacy endpoints.
Note that in both trials a one month course of DAPT was mandated.
The field of interventional cardiology has come a long way in such a
short time. Despite the fact that we hear about new technical advances
at almost each meeting during the year, there are still a host of unanswered questions. When can we expect easier approaches to chronic
coronary total occlusions? Will we have a user-friendly, successful
transcatheter mitral valve? Will we have a transcatheter mitral annuloplasty device? What role will these new technologies play in patient
care strategy? Will tricuspid valve interventions be the next frontier?
All of these questions have widespread ramifications for involvement of
interventional cardiologists—both on the clinical and research side.
There is so much to do and so much to learn. That is the good news.
However, there is a cautionary note as well. Our non-interventional
colleagues have not been sitting idly by. Great strides have been made
in the medical therapy of coronary disease and in prevention. Some
“preventive” cardiologists predict that the PCSK9 inhibitors will greatly
impact the development of atherosclerotic coronary disease. Some go as
far as to say that coronary disease can be “prevented,” and there is talk
of immunizing against atherosclerosis. It sounds crazy, but these are
smart people. In the future we interventionalists may find that our role
in patient care is seriously diminished. That is not all bad. I have often
said that if we do our job correctly as cardiologists, we ultimately will
have no job!
Despite the fact that we
hear about new technical
advances at almost each
meeting during the year,
there are still a host of
unanswered questions.
What do you hope to bring to CardioSource WorldNews:
Interventions? What can readers anticipate seeing in future
issues in CSI?
CSI has been a terrific source of interventional cardiology news and
education. It is timely, informative, and useful to a wide range of people
involved in cardiac interventional care. New editors should have new
ideas, and I am no exception. I plan to expand the content of CSI so
that more groups of interventionalists (and their colleagues) will have
a voice. The list includes having CSI content devoted to electrophysiology, topics important to fellows in training, and involvement of administrators of catheterization laboratories as a first cut. I plan to have a
personal editor’s commentary and for each issue will pick one or two of
the most informative recent reports from JACC Interventions and editorialize them. This increase in content will hopefully broaden readership
and interest in CSI. Lastly, I must appeal to the readership as well. If
any of the readers of CSI has ideas that might strengthen CSI, my door
is always open for comments and suggestions. ■
ACC.org/CSWNInterventions
With the supportive data from
LEADERS-FREE, is it time to finally
be rid of BMS on interventional
shelves?
So what can we take away from these two studies? Certainly the
ZEUS Trial proves the concept that in patients with high bleeding risk
who need coronary stenting DAPT for 30 days has greater safety and
efficacy in patients who had DES rather than BMS implanted. But, like so
many studies, questions still remain unanswered. How do the ZEUS data
relate to even more contemporary stent platforms? Can such platforms
also perform well (compared to BMS platforms) in patients with only
short term, 30-day DAPT therapy? So many studies today end with the
statement: “Future studies are needed to confirm these data,” and the
ZEUS trial is no exception. Nonetheless, with the supportive data from
LEADERS-FREE, is it time to finally be rid of BMS on interventional
shelves? With mounting evidence that even patients with high bleeding
risk are better served with a DES than a BMS, and DAPT is only needed
for 30 days, perhaps it is time to agree BMS are not needed any longer
even for those patients who might have benefitted.
But then again, there are those patients who steadfastly refuse to take
DAPT, or cannot afford it. ■
REFERENCES:
1. Ariotti S, el al. JACC Int. 2016;9(5):426-36.
2. Mauri L et al. N Engl J Med. 2014; 371(23):2155-66.
3. Dewilde WL et al. Lancet. 2013;381(9872):1107-15.
4. Fiedler KA et al. J Am Coll Cardiol. 2015;65(16):1619-29.
5. Urban P et al. N Engl J Med. 2015;373:2038-47.
Peter C. Block, MD, is a Professor of Medicine and Cardiology at Emory University, in
Atlanta, GA. He is the Director of Interventional Cardiology and Research at the Emory
Heart & Vascular Center.
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