Safety and efficacy outcomes of first and second generation durable polymer drug eluting stents and biodegradable polymer biolimus eluting stents in clinical practice: comprehensive network meta-analysis
BMJ 2013;347:f6530

Abstract
Objectives To investigate the safety and efficacy of durable polymer drug eluting stents (DES) and biodegradable polymer biolimus eluting stents (biolimus-ES).

Design
Network meta-analysis of randomised controlled trials.

Data sources and study selection
Medline, Google Scholar, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) database search for randomised controlled trials comparing at least two of durable polymer sirolimus eluting stents (sirolimus-ES) and paclitaxel eluting stents (paclitaxel-ES), newer durable polymer everolimus eluting stents (everolimus-ES), Endeavor and Resolute zotarolimus eluting stents (zotarolimus-ES), and biodegradable polymer biolimus-ES.

Primary outcomes Safety (death, myocardial infarction, definite or probable stent thrombosis) and efficacy (target lesion and target vessel revascularisation) assessed at up to one year and beyond.

Results
60 randomised controlled trials were compared involving 63?242 patients with stable coronary artery disease or acute coronary syndrome treated with a DES.
At one year, there were no differences in mortality among devices. Resolute and Endeavor zotarolimus-ES, everolimus-ES, and sirolimus-ES, but not biodegradable polymer biolimus-ES, were associated with significantly reduced odds of myocardial infarction (by 29-34%) compared with paclitaxel-ES.
Compared with everolimus-ES, biodegradable polymer biolimus-ES were associated with significantly increased odds of myocardial infarction (by 29%), while Endeavor zotarolimus-ES and paclitaxel-ES were associated with significantly increased odds of stent thrombosis.
All investigated DES were similar with regards to efficacy endpoints, except for Endeavor zotarolimus-ES and paclitaxel-ES, which were associated with significantly increased the odds of target lesion and target vessel revascularisations compared with other devices.
Direction of results beyond one year did not diverge from the findings for up to one year follow-up. Bayesian probability curves showed a gradient in the magnitude of effect, with everolimus-ES and Resolute zotarolimus-ES offering the highest safety profiles.

Conclusions
The newer durable polymer everolimus-ES and Resolute zotarolimus-ES and the biodegradable polymer biolimus-ES maintain the efficacy of sirolimus-ES; however, for safety endpoints, differences become apparent, with everolimus-ES and Resolute zotarolimus-ES emerging as the safest stents to date.

What is already known on this topic

Coronary stents are widely used to treat patients with coronary artery disease, with drug eluting stents (DES) being more efficacious than bare metal stents
Among DES, the second generation durable polymer stents (with everolimus eluting being the most studied prototype) are safer than first generation durable polymer DES and bare metal stents
The efficacy and safety profile of biodegradable polymer stents (with biolimus eluting being the most widely used) compared with first and second generation durable polymer DES is controversial.

What this study adds

This large network meta-analysis of randomised trials on DES compares durable with biodegradable polymer stents and provides a clear visual ranking of the efficacy and safety of all of the most used DES
The newer durable polymer everolimus and Resolute zotarolimus eluting stents, as well as the biodegradable polymer biolimus eluting stents, provide similar efficacy to first generation sirolimus eluting stents. Everolimus and Resolute zotarolimus eluting stents are the safest devices to date.

G Mohan.