Adnan Kastrati, MD, is a Professor of Cardiology and Director of the Catheterization Laboratory at Detsches Herzzentrum in Munich, Germany. Dr Kastrati has served a pivotal role in the design and conduction of a large number of clinical trials involving more than 30,000 patients and he has served on the steering committees of the Stenting and Antithrombotic Regimen (ISAR) and Harmonizing Outcomes with RevascularIZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trials, as well as the Optimal Antiplatelet Strategy for InterventionS 7 (OASIS-7) trial. Dr Kastrati is an editorial board member for the European Heart Journal, EuroInterventions, among others. His research in the field of acute coronary syndrome and interventional cardiology has led to the publication of more than 230 original articles in journals including Circulation, Journal of the American College of Cardiology, Lancet, Journal of the American Medical Association, and New England Journal of Medicine. Dr Kastrati received his medical degree from the University of Tirana in Albania, where he completed a residency in internal medicine and cardiology. Subsequently, he earned a fellowship in intervention cardiology at the University of Heidelberg in Germany. Adnan Kastrati, MD, has indicated the following relevant financial relationships: speaker for Bristol-Meyers Squibb Company, Cordis Corporation, Eli Lilly and Company, and The Medicines Company.
Hello, I am Adnan Kastrati, an interventional cardiologist from Deutsches Herzzentrum in Munich, Germany. This year, we were lucky to host the European Society of Cardiology (ESC) Congress 2008, and I was very delighted to hear that more than 30,000 people from 130 countries—the largest number ever recorded at an ESC Congress—participated in this event. This year’s meeting was dominated by two randomized trials that compared percutaneous coronary interventions (PCI) with use of drug-eluting stents (DES) with coronary bypass surgery (CABG) in patients with left-main or three-vessel coronary disease, and in diabetic patients. There were also several studies that focused on antiplatelet therapy. In addition, new data and comments from various interventional cardiology experts strengthened the conviction that DES are a safe treatment option, provided that current recommendations are followed regarding adjunct antiplatelet therapy. On Monday, September 1, we had the opportunity to learn about the results of two randomized clinical trials comparing PCI with CABG in high-risk patients with coronary artery disease (CAD). There was great interest surrounding these trials, especially after the confusion created by the COURAGE trial about the ability of PCI to compete with other treatment options for patients with CAD. We respect the great level of energy, engagement, and cooperation required among cardiologists and cardiac surgeons to conduct such trials, and the investigators are to be commended for the successful completion of these complex studies. In the first study—the SYNTAX trial—1,800 patients with left main or three-vessel disease were randomly assigned to receive either DES (a paclitaxel-eluting stent) or CABG. It was very reassuring to see that the overall 1-year rate of serious adverse events such as death, myocardial infarction (MI), and cerebrovascular accident, was low and that there was no difference between the two strategies (7.6% for DES and 7.7% for CABG). Although the primary endpoint, the composite of death, MI, cerebrovascular accident, and repeat revascularization procedure favored CABG with 12.1% versus 17.8% in the DES group, the difference was only generated by a lower rate of repeat revascularization with CABG (5.9% versus 13.7% with DES; P<0.0001). I doubt that the increased need for revascularization procedures observed with DES will be reason enough to cause patients with these coronary pathologies to choose the surgical option, especially considering that CABG in the SYNTAX trial was associated with an increased risk of cerebrovascular accident, with a 1-year incidence of 2.2% versus 0.6% in the DES group. In the second, smaller CARDia trial, PCI was compared with CABG in 510 patients with type 2 diabetes and CAD. About 70% of the PCI patients received DES. In line with the results of the SYNTAX trial, the CARDia trial showed no difference in the primary endpoint of death, MI, or stroke at 1 year, with 10.2% for CABG and 11.6% for PCI (P=0.63). The trial also mirrored the SYNTAX results regarding repeat revascularization (in favor of CABG) and stroke (in favor of PCI). Summarizing the results of these two trials, I am confident that the excellent outcomes achieved with PCI, along with the greater comfort provided to the patient by this procedure, will induce a further expansion of the use of PCI in patients with CAD. Two subset analyses from the TRITON-TIMI 38 trial compared prasugrel† with clopidogrel in patients with acute coronary syndrome (ACS). In the first substudy involving patients with diabetes, the investigators found a reduction in the 15-month risk of cardiovascular death, MI, and stroke with prasugrel (12.2% from 17.0% observed with clopidogrel). Notably, no increased risk of major bleeding was seen with prasugrel in patients with diabetes. In the second substudy involving patients with ST-segment elevation MI (STEMI), the investigators found that STEMI patients taking prasugrel experienced a reduction in ischemic events without any increase in bleeding. It is interesting that even though these subpopulations of patients are known to have higher risk, they may nevertheless benefit from replacement of clopidogrel with prasugrel without experiencing an excess bleeding risk. Prasugrel is not yet approved by FDA, but their ruling is expected late September, 2008. For me, the take-home message of this meeting is that PCI with the use of more effective and safer DES, under the protection of better tailored antiplatelet therapies to the individual patient, will increase its dominance over other treatment options of patients with CAD. I am very excited about the new evidence that is expected to emerge from upcoming meetings including Transcatheter Cardiovascular Therapeutics (TCT) in Washington, DC, and the American Heart Association (AHA) in New Orleans, LA, later this year. †Investigational agent; not yet FDA approved
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