According to the XIMA (Xience or Vision stents for the management of angina in the elderly) study, the use of drug-eluting stents in patients aged ≥80 years is associated with less myocardial infarction and target vessel revascularisation than is the use of bare metal stents. Also, the longer use of dual antiplatelet therapy (DAPT) with drug-eluting stents is not associated with an increased risk of bleeding.
Writing in the Journal of the American College of Cardiology, study authors Adam de Belder (Department of Cardiology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK) and others state that use of drug-eluting stents may be warranted in elderly patients because they often have complex coronary artery disease, but add: “Prolonged use of DAPT puts them at higher risk of major bleeding complications. Non-compliance with DAPT may also be likely in elderly patients and this would put them at higher risk of stent thrombosis.”
Therefore, the XIMA study was designed to review the hypothesis that the use of drug-eluting stents in patients aged ≥80 years would be superior to the use of bare metal stents. The primary endpoint was a composite of mortality, myocardial infarction, target vessel revascularisation, cerebrovascular accident, or severe haemorrhage.
In the study, 800 octogenarian patients aged ≥80 with stable angina or acute coronary syndromes were randomised to receive a bare metal stent (401; Vision, Abbott Vascular) or a everolimus-eluting stent (Xience, Abbott Vascular). They were followed up at six months and at 12 months. The rate of the cumulative primary endpoint did not significantly differ between groups—18.7% for bare metal stents vs. 14.3% for drug-eluting stents (p=0.092). However, the authors report that in two predefined subgroup analyses (radial access and multivessel disease), the use of drug-eluting stents was found to reduce the rate of the primary endpoint. De Belder et al note: “A potential confounder in this trial was the unpredictable nature of mortality in this age group. Indeed, the drug-eluting stent group had a significantly higher rate of non-cardiac mortality than the bare metal stent group; a finding that might have had an important bearing on the primary endpoint.”
At one year, the rate of target vessel revascularisation was significantly lower in the drug-eluting stent group compared with the bare metal stent group (2% vs. 7%, respectively; p=0.0009). The rate of myocardial infarction was also significantly lower at one year with drug-eluting stents (4.3% vs. 8.7%; respectively p=0.014). The rate of major haemorrhage or cerebrovascular accident did not differ between groups.
In accompanying editorial, George Dangas (Cardiovascular Institute, Mount Sinai Medical Center, New York, USA) comments: “One may suggest a clinical strategy of everolimus-eluting stenting via radial access in elderly patients appears attractive, as it reduces vascular complications while improving rates of myocardial infarction and target vessel revascularisation.”