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Original Article

Sirolimus-Eluting versus Uncoated Stents in Acute Myocardial Infarction

Christian Spaulding, M.D., Patrick Henry, M.D., Ph.D., Emmanuel Teiger, M.D., Ph.D., Kevin Beatt, M.B., B.S., Ph.D., Ezio Bramucci, M.D., Didier Carrié, M.D., Michel S. Slama, M.D., Bela Merkely, M.D., Ph.D., Andrejs Erglis, M.D., Ph.D., Massimo Margheri, M.D., Olivier Varenne, M.D., Ph.D., Ana Cebrian, Ph.D., Hans-Peter Stoll, M.D., David B. Snead, Ph.D., and Christoph Bode, M.D. for the TYPHOON Investigators

N Engl J Med 2006; 355:1093-1104September 14, 2006

Abstract

Background

Sirolimus-eluting stents reduce rates of restenosis and reintervention, as compared with uncoated stents. Data are limited regarding the safety and efficacy of such stents in primary percutaneous coronary intervention (PCI) for acute myocardial infarction with ST-segment elevation.

Methods

We performed a single-blind, multicenter, prospectively randomized trial to compare sirolimus-eluting stents with uncoated stents in primary PCI for acute myocardial infarction with ST-segment elevation. The trial included 712 patients at 48 medical centers. The primary end point was target-vessel failure at 1 year after the procedure, defined as target-vessel–related death, recurrent myocardial infarction, or target-vessel revascularization. A follow-up angiographic substudy was performed at 8 months among 174 patients from selected centers.

Results

The rate of the primary end point was significantly lower in the sirolimus-stent group than in the uncoated-stent group (7.3% vs. 14.3%, P=0.004). This reduction was driven by a decrease in the rate of target-vessel revascularization (5.6% and 13.4%, respectively; P<0.001). There was no significant difference between the two groups in the rate of death (2.3% and 2.2%, respectively; P=1.00), reinfarction (1.1% and 1.4%, respectively; P=1.00), or stent thrombosis (3.4% and 3.6%, respectively; P=1.00). The degree of neointimal proliferation, as assessed by the mean (±SD) in-stent late luminal loss, was significantly lower in the sirolimus-stent group (0.14±0.49 mm, vs. 0.83±0.52 mm in the uncoated stent group; P<0.001).

Conclusions

Among selected patients with acute myocardial infarction, the use of sirolimus-eluting stents significantly reduced the rate of target-vessel revascularization at 1 year. (ClinicalTrials.gov number, NCT00232830.)

Media in This Article

Figure 1Enrollment and Outcomes.
Figure 2Actuarial Rate of Survival Free from Target-Vessel Failure among Patients Who Received Either a Sirolimus-Eluting Stent or an Uncoated Stent.
Article

The use of sirolimus-eluting coronary-artery stents significantly reduces the incidence of restenosis after percutaneous coronary intervention (PCI), as compared with the use of uncoated stents.1-3 However, most randomized trials evaluating sirolimus-eluting stents have excluded patients with acute myocardial infarction with ST-segment elevation. Small series of patients with acute myocardial infarction have shown that the implantation of a sirolimus-eluting stent is associated with a low rate of restenosis.4,5 In the Single High-Dose Bolus Tirofiban and Sirolimus-Eluting Stent vs. Abciximab and Bare-Metal Stent in Myocardial Infarction (STRATEGY) trial, the use of sirolimus-eluting stents reduced cardiovascular events, as compared with the use of uncoated stents, in a small group of patients undergoing primary PCI. However, the design of the trial specified the use of different glycoprotein IIb/IIIa inhibitors in each of the two groups to mitigate the greater cost of the drug-eluting stents, which raised the possibility that the benefit was influenced by the specific antiplatelet regimen.6

We therefore designed a prospective, randomized, multicenter trial comparing the effectiveness of sirolimus-eluting stents with that of uncoated stents in primary PCI for acute myocardial infarction with ST-segment elevation.

Methods

Enrollment and Assignment of Patients

We enrolled patients at 48 centers in 15 countries to participate in the Trial to Assess the Use of the Cypher Stent in Acute Myocardial Infarction Treated with Balloon Angioplasty (TYPHOON). The study protocol was approved by the ethics committee at each participating institution and was conducted according to the principles of the Declaration of Helsinki. All patients gave written informed consent before enrollment. The study was conducted from October 2003 to October 2005.

Patients were eligible for the trial if their symptoms began less than 12 hours before catheterization and if the electrocardiogram showed ST-segment elevation (at least 1 mm in two or more standard leads or at least 2 mm in two or more contiguous precordial leads). Clinical criteria for exclusion included the administration of fibrinolytic agents for the index infarction, overt acute heart failure, a previously documented left ventricular ejection fraction of less than 30%, previous myocardial infarction, and an estimated life expectancy of less than 12 months.

Diagnostic Angiography and Primary Intervention

Patients were premedicated with aspirin (at least 100 mg) and unfractionated heparin (5000 to 10,000 IU). A loading dose of 300 mg of clopidogrel was administered either before or immediately after PCI. Coronary angiography was performed through the femoral or radial artery with the use of standard techniques.

Selection and Randomization

The trial protocol required visualization of the culprit lesion before randomization, in order to determine whether the angiographic criteria for inclusion or exclusion were met. Randomization was therefore performed either immediately after coronary angiography if the infarct-related vessel was spontaneously patent or after reestablishing coronary-artery blood flow by the placement of a guidewire or by balloon angioplasty.

Criteria for angiographic exclusion included previous PCI of the infarct-related vessel, excessive tortuosity or calcification, ostial or multiple lesions, massive thrombus in the infarct-related artery, bifurcation or left main coronary-artery disease, and severe multivessel disease requiring surgical revascularization. Patients were finally included and randomly assigned to a treatment group if the target lesion had a maximum length of 30 mm and was located in a native coronary artery with a reference-vessel diameter of 2.25 mm to 3.50 mm.

Random assignments to the treatment groups were generated in blocks of four or six and were distributed in sealed envelopes to each participating center. Patients were randomly assigned to the groups in a 1:1 ratio. Patients received either a sirolimus-eluting stent (Cypher or Cypher Select, Cordis, Johnson & Johnson) or any commercially available uncoated stent. Patients, but not investigators, were unaware of the treatment assignment.

Stent Implantation

Direct implantation of a stent without previous balloon angioplasty was allowed if the culprit lesion was adequately visualized either spontaneously or after guidewire placement. In the case of insufficient stent expansion, the stent was dilated after placement with another angioplasty balloon that was shorter than the total length of the stent. Oversizing and additional high-pressure dilation after the initial procedure were not recommended. If more than one stent was implanted, the same type of stent (sirolimus-eluting or uncoated) was recommended. Intervention in noninfarct-related arteries during the initial procedure was discouraged.

Heparin was administered throughout the procedure in order to maintain an activated clotting time of 250 seconds or longer. Administration of platelet glycoprotein IIb/IIIa–receptor inhibitors was left to the investigator's discretion.

Follow-up

Clinical follow-up was performed at 30 days and at 6 and 12 months after the procedure. Combined antiplatelet therapy included daily administration of aspirin (100 mg) and either clopidogrel (75 mg) or ticlopidine (250 mg). Dual antiplatelet therapy was recommended for at least 6 months, and aspirin therapy was recommended indefinitely. Noninvasive testing to assess for evidence of ischemia was recommended before repeated revascularization. Patients were unaware of their treatment assignments throughout the follow-up period.

Angiographic follow-up at 8 months was planned for 200 patients at 12 centers. In these selected centers, consecutive patients were enrolled in the angiographic substudy until the total number of patients reached 210.

Quantitative Coronary Angiography

Technicians at an independent angiographic core laboratory (BioImaging, Leiden, the Netherlands), who were unaware of treatment assignment, analyzed all angiographic images with the use of edge-detection techniques.7 Binary restenosis was defined as stenosis of more than 50% of the luminal diameter. Late luminal loss was calculated as the difference between the minimum luminal diameter immediately after the procedure and at 8 months. Flow in the infarct-related vessel was graded according to the Thrombolysis in Myocardial Infarction (TIMI) trial classification.8

Primary and Secondary End Points

The primary end point of the study was target-vessel failure, defined as the composite of target-vessel revascularization, recurrent infarction, or target-vessel–related death at 1 year. The clinical events committee reviewed and adjudicated all serious clinical events, including stent thrombosis.

Target-vessel revascularization was defined as repeated PCI or bypass grafting of the target vessel, driven by clinical symptoms of myocardial ischemia, a positive stress test, electrocardiographic evidence of ischemic changes at rest attributable to the target vessel, or an in-lesion stenosis of more than 70% of the reference luminal diameter by visual estimate.

Recurrent infarction was defined as the recurrence of clinical symptoms or the occurrence of electrocardiographic changes accompanied by a new elevation in levels of creatine kinase, creatine kinase MB enzyme, or both. The level of creatine kinase required for the diagnosis of reinfarction depended on the interval from the index infarction: the creatine kinase level had to be at least 1.5 times the previous value if new symptoms appeared within 48 hours and at least 3 times the upper limit of normal if new symptoms appeared after 48 hours.

Death from cardiac causes included death from acute myocardial infarction, cardiac perforation, or pericardial tamponade; an arrhythmia or conduction abnormality; complications of the interventional procedure at baseline; stroke (including bleeding) within 30 days after the procedure or in connection with the procedure; and all deaths that could not be clearly attributed to a noncardiac cause.

The secondary end points of the trial included the rate of successful treatment of the lesion, defined by residual stenosis of less than 50% of the reference luminal diameter on quantitative coronary analysis and a TIMI flow grade of 3, and in-stent late luminal loss on quantitative coronary analysis at 8 months.

Definition of Stent Thrombosis

Stent thrombosis was classified as acute if it occurred within 24 hours after the index procedure, subacute if it occurred between 1 and 30 days, and late if it occurred after 30 days. Acute and subacute stent thrombosis were defined as angiographic proof of vessel occlusion, any recurrent Q-wave myocardial infarction in the territory of the stented vessel, or any death from cardiac causes. Late stent thrombosis was defined as any recurrent myocardial infarction with angiographic proof of vessel occlusion.

Study Design and Administration

Our study was proposed to the industry sponsor by four of the academic investigators: Drs. Henry, Spaulding, Teiger, and Slama. The same investigators wrote the final version of the protocol in collaboration with the industry sponsor, and the steering committee approved the design. Dr. Spaulding designed the statistical-analysis plan in collaboration with the sponsor.

Data were collected with the use of an electronic case-report form through a secured Internet-based Web site. A clinical research organization (Hesperion, Allschwil, Switzerland) performed all study monitoring, data management, and statistical analysis. The industry sponsor had no direct role in the collection or analysis of data. The steering committee had unrestricted access to the data and made all decisions about publication independently of the sponsor. Dr. Spaulding assumes overall responsibility for the integrity of the data, the accuracy of the data analyses, and the completeness of the material reported.

Statistical Analysis

The planned enrollment of 700 patients provided a statistical power of 80% to detect a 47% reduction in the rate of the primary end point at 1 year (from 17% in the uncoated-stent group to 9% in the sirolimus-stent group) with a 5% rate of false positive results in a two-sided test. The estimated enrollment for the angiographic substudy was based on an assumed in-stent late luminal loss of 0.43 mm in the sirolimus-stent group and 0.76 mm in the uncoated-stent group at 8 months, with an SD of 0.7 mm for both groups.2,9 After correction for loss to follow-up, we estimated that the enrollment of 200 patients provided 80% power with a false positive rate of 5% in a two-sided test.

All analyses were based on the intention to treat. The differences between the treatment groups were evaluated by analysis of variance or Wilcoxon rank-sum scores for continuous variables, if appropriate. Fisher's exact test was used for the analysis of categorical variables. The rate of survival free from target-vessel failure during the 1-year follow-up period was analyzed by the Kaplan–Meier method, and the difference in survival curves between the groups was assessed with the log-rank test. To test whether initial differences between the two treatment groups influenced the difference in outcome, multiple logistic-regression analysis was performed, controlling for all variables that were found to be significantly different at baseline. All statistical analyses were performed with the use of SAS software, version 8.2 (SAS Institute), and all reported P values are two-sided.

Results

Study Patients

Between October 2003 and September 2004, 2019 patients were screened and 715 were randomly assigned to the two treatment groups (356 to the sirolimus-stent group and 359 to the uncoated-stent group) (Figure 1Figure 1Enrollment and Outcomes.). The most frequent reason for exclusion was fibrinolytic therapy for the index infarction. After randomization and treatment with the assigned stent, one patient in the sirolimus-stent group and two in the uncoated-stent group withdrew their consent to participate in the study.

Baseline Characteristics and Medications Used

Patients in the uncoated-stent group were slightly older and had a higher rate of previous PCI involving a nontarget coronary vessel, a lower rate of culprit lesions in the left anterior descending coronary artery, and a higher rate of triple-vessel disease (Table 1Table 1Baseline Characteristics of the Patients.). In both groups, the median time from the onset of chest pain to hospital admission was less than 4 hours, and the median interval between arrival at the hospital and inflation of the balloon catheter was 60 minutes. The rate of use of glycoprotein IIb/IIIa–receptor inhibitors and the specific agents used did not vary significantly between the two groups (Table 2Table 2Procedural Results and Use of Medication during the Trial.).

Clinical Outcome at 1 Year

The primary end point of the study — target-vessel failure at 1 year — occurred in 7.3% of patients in the sirolimus-stent group and in 14.3% in the uncoated-stent group (P=0.004) (Table 3Table 3Clinical Events at 1 Year.). This difference was due almost entirely to significant differences in the rates of target-vessel revascularization. There was no significant difference between the sirolimus-stent group and the uncoated-stent group in the rates of death (2.3% and 2.2%, respectively; P=1.00), recurrent myocardial infarction (1.1% and 1.4%, respectively; P=1.00), or in-stent thrombosis (3.4% and 3.6%, respectively; P=1.00). The actuarial rate of survival free from target-vessel failure was significantly higher in the sirolimus-stent group than in the uncoated-stent group (92.5% vs. 85.2%, P<0.001) (Figure 2Figure 2Actuarial Rate of Survival Free from Target-Vessel Failure among Patients Who Received Either a Sirolimus-Eluting Stent or an Uncoated Stent.).

Multivariate analysis of the primary end point was performed to control for all significant variables in Table 1 and Table 2, including the use of clopidogrel, at 6 months. On the basis of this adjusted analysis, patients in the sirolimus-stent group were less than half as likely as those in the uncoated-stent group to have target-vessel failure (odds ratio, 0.41; P=0.001).

Angiographic Follow-up Study

Of the 210 patients included in the angiographic substudy, 174 underwent angiography at 8 months (82.8%) and 170 had qualifying angiograms (81.0%) (Figure 1 and Table 4Table 4Angiographic Measurements Obtained at the Time of the Index Procedure and at Follow-up at 8 Months). Patients in the angiographic study, as compared with those not in the study, tended to have higher rates of target-vessel failure (13.3% vs. 9.8%, P=0.19) and revascularization (12.4% vs. 8.4%, P=0.12), although these differences were not significant. However, the reduction in target-vessel failure in the sirolimus-stent groups was similar whether or not follow-up angiography was performed. At 8 months, sirolimus-eluting stents, as compared with uncoated stents, were associated with significant mean reductions in in-stent late luminal loss (0.14±0.49 mm vs. 0.83±0.52 mm, P<0.001) and in-stent restenosis (3.5% vs. 20.3%, P=0.001).

Discussion

In our trial, the use of sirolimus-eluting stents during primary PCI was associated with a reduction in the incidence of target-vessel failure at 1 year, as compared with the use of uncoated stents (7.3% vs. 14.3%, P=0.004). This difference was mainly driven by a reduction in the incidence of target-vessel revascularization. The results of the angiographic follow-up study suggest that the mechanism of benefit involves the suppression of neointimal proliferation among patients receiving sirolimus-eluting stents. The average in-stent late luminal loss in the sirolimus-stent group in our study was similar to that in previous studies of patients undergoing elective procedures.2,3,10

Rates of stent thrombosis were similar in the sirolimus-stent and uncoated-stent groups (3.4% and 3.6%, respectively; P=1.00). These rates were higher than those in previous studies. Reported rates of stent thrombosis vary according to the clinical presentation and the definition used. In recent trials of sirolimus-eluting stents that included only elective cases and used the same definition that we used in our trial, cumulative rates of stent thrombosis ranged from 0 to 1.1%.1-3,10 A higher rate (2.0%) was reported for sirolimus-eluting stents in the Sirolimus-Eluting Stent Compared with Paclitaxel-Eluting Stent for Coronary Revascularization (SIRTAX) trial (a comparison of the Cypher stent and the Taxus stent), which included both patients with and those without acute myocardial infarction.11 Elsewhere in this issue of the Journal, Laarman et al.12 report the results of the Paclitaxel-Eluting Stent versus Conventional Stent in Myocardial Infarction with ST-Segment Elevation (PASSION) trial, which showed a lower overall rate of stent thrombosis (1%) than did our study. However, angiographic proof was required for the diagnosis of stent thrombosis, and adjudication was not performed by an independent clinical events committee. The rates of stent thrombosis in the STRATEGY trial were 0% in the group receiving sirolimus-eluting stents and 3% in the group receiving uncoated stents.6 The 1-month rate of stent thrombosis in trials and registries with uncoated stents in acute myocardial infarction ranges from 0.9 to 4.3%.9,13-19

Procedural factors may have contributed to in-stent thrombosis in our study. Suboptimal procedural regimens of aspirin and heparin were allowed, with minimal aspirin doses of 100 mg and a minimal activated clotting time of 250 seconds, in contrast to recent recommendations.20 Furthermore, incomplete stent deployment favoring in-stent thrombosis cannot be ruled out, since the mean residual stenosis after the procedure was higher in both groups than that in previous studies.1,2 Finally, our definition of acute and subacute thrombosis was broad and included both death and repeated myocardial infarction if angiographic proof of stent patency was not available. In contrast, the definition of late thrombosis required angiographic proof of stent thrombosis. Accordingly, 30-day rates of stent thrombosis may have been overestimated and those of late thrombosis underestimated.

In comparison with our study, trials and registries of primary PCI in patients with acute myocardial infarction with ST-segment elevation have reported lower rates of repeated revascularization. In fact, our rates are similar to those of previous studies in patients in stable condition.9,13-18 This finding may be related to the effect of angiographic follow-up in a subgroup of patients, since revascularization rates tended to be higher among patients undergoing follow-up angiography. Nevertheless, the significant difference in the rates of target-vessel failure was maintained in the subgroup of patients without angiographic follow-up. Furthermore, noninvasive testing was performed on a routine basis at 6 months, an approach that may have led to an increased rate of ischemia-driven revascularization. Another factor may have been the speed of intervention (median interval from arrival at the hospital to inflation of the balloon catheter, 60 minutes), which left patients with a relatively large amount of viable myocardium at risk. In the PASSION trial, the revascularization rate in the group receiving uncoated stents was surprisingly low, and the incidence of the primary end point was lower than the expected rate. The enrollment of fewer patients with diabetes and more patients with larger target vessels in the PASSION trial may account for these differences.12

Our results cannot be generalized to all patients with acute myocardial infarction, since high-risk patients were excluded. Furthermore, our findings cannot be extended to other drug-eluting stents. Despite adjudication of events by an independent clinical events committee, the single-blind study design is an obvious limitation. This is especially true since the beneficial effect of sirolimus-eluting stents on the primary end point was almost entirely due to a reduction in target-vessel revascularization, which was performed by investigators who were not specifically blinded to the study assignment of each patient. Although an analysis that was adjusted for differences between treatment groups in baseline characteristics did not change the findings, other variables might have influenced them. Finally, an assessment of long-term safety and durability will require longer follow-up of a larger cohort of patients.

In summary, in our study, patients with acute myocardial infarction with ST-segment elevation who received sirolimus-eluting stents had a significantly lower rate of target-vessel failure than those who received uncoated stents. This difference was due almost entirely to a significant reduction in the rate of target-vessel revascularization. An angiographic follow-up study showed significant reductions in in-stent restenosis and in-stent late luminal loss.

Supported by Cordis, Johnson & Johnson.

Drs. Spaulding, Henry, Teiger, Beatt, Carrié, Slama, Varenne, and Bode report having received consulting or lecture fees from Cordis, Johnson & Johnson; and Dr. Beatt, grant support from Cordis, Johnson & Johnson. Drs. Cebrian, Stoll, and Snead are full-time employees of Cordis, Johnson & Johnson, and Drs. Stoll and Snead report holding equity interest in the company. No other potential conflict of interest relevant to this article was reported.

We are indebted to the patients who agreed to participate in the study; to the study coordinators, technicians, and nurses in the participating centers; and to Rita Dalal and Lorraine Wheeler for their editorial assistance.

Source Information

From Assistance Publique–Hôpitaux de Paris (AP–HP) Cochin Hospital, Paris 5 Medical School Rene Descartes University and INSERM U780, Paris (C.S., O.V.); AP–HP Lariboisiere Hospital, Paris 7 Medical School University Denis Diderot, Paris (P.H.); AP–HP Henri Mondor Hospital, Paris 12 Medical School, Créteil (E.T.); Hospital Rangueil, Toulouse (D.C.); and AP–HP Antoine Béclère Hospital, Paris 12 Medical School Paris Sud University, Clamart (M.S.S.) — all in France; Mayday University Hospital, London (K.B.); Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia (E.B.), and Azienda Universitaria Ospedaliera Careggi, Florence (M.M.) — both in Italy; Semmelweis University, Budapest (B.M.); Pauls Stradins University Hospital, Riga, Latvia (A.E.); Cordis (Johnson & Johnson), Waterloo, Belgium (A.C., H.-P.S.) and Warren, NJ (D.B.S.); and the University of Freiburg, Freiburg, Germany (C.B.).

Address reprint requests to Dr. Spaulding at Cochin Hospital, 27 rue du Faubourg St. Jacques, 75014 Paris, or at .

Members of the Trial to Assess the Use of the Cypher Stent in Acute Myocardial Infarction Treated with Balloon Angioplasty (TYPHOON) are listed in the Appendix.

Appendix

The following investigators and institutions participated in the TYPHOON study: Steering Committee: C. Spaulding, C. Bode, E. Bramucci, P. Henry, E. Teiger, D. Carrie, M. Slama, K. Beatt; Sponsor: Cordis, Warren, NJ — D. Donohoe (medical director), D. Snead, R. Dalal, S. Sun; Cordis, Waterloo, Belgium — H.-P. Stoll (program director), A. Cebrian (program coordination), L. Wheeler; Data and Safety Monitoring Board: B. Meier, Switzerland; B. Lancelin, France; J.-F. Neumann, Germany; Clinical Events Committee: A. Caspi (chair), Israel; G. Maurer, Austria; S. Cook, Switzerland; Data Management and Monitoring: Hesperion, Clinical Development Services, Allschwil, Switzerland — V. Charlon (director); C. Berge; P. Rush; Electronic Data Capture: PPD GlobalView Web Services, New Hope, MN; Core Angiographic Laboratory: Bio Imaging Technologies, Leiden, the Netherlands — A. Van Weert (director); Clinical Sites: Royal Perth Hospital, Perth, Australia — R. Clugston, M. Bonner; Hôpital Cantonal de Genève, Geneva — E. Camenzind, N. Masson; Nemocnice Ceske, Budejovice, Czech Republic — L. Pesl; Poruba School of Medicine, Poruba, Czech Republic — R. Stipal, L. Pleva; Medizinische Universitätsklinik Freiburg, Freiburg, Germany — C. Bode, M. Zehender, S. Richter; Universitätskliniken des Saarlandes, Homburg Saar, Germany — G. Nickenig, N. Werner; Medizinische Klinik und Poliklinik Johannes-Gutenberg-Universität, Mainz, Germany — F. Post; Københavns Amtssygehus Gentofte, Hellerup, Denmark — U. Abildgaard, A. Galloe; Virgen de la Arrixaca, Murcia, Spain — M. Valdés, E. Pinar; Hôpital Européen Georges Pompidou, Paris — N. Danchin; Institut Mutualiste Montsouris, Paris — A. Dibie, F. Larrazet, F. Philippe; Clinique du Millénaire, Montpellier, France — X. De Boisgelin, G. Levy; Hôpital Lariboisiere, Paris — P. Henry, G. Sideris, R. Fressonnet; Hôpital Bichat, Paris — J.-M. Juliard, P. Aubry; Hôpital Tenon, Paris — P. Michel, E. Garbarz; Hôpital Béclère, Clamart, France — M. Slama, P. Colin; Hôpital Cochin, Paris — C. Spaulding, O. Varenne; Henri Mondor Hospital, Paris — E. Teiger, J. Dubois-Randé, S. Champagne; Centre Hospitalier Universitaire Toulouse–Hôpital Rangueil, Toulouse, France — D. Carrié, J. Roncalli, J. Cahuzac; Clinique Les Fleurs, Marseille, France — P. Commeau, P. Barragan; Hôpital Guillaume et René Laennec, Centre Hospitalier Universitaire Nord, St. Herblain, France — P. Guerin, A. Tirouvanziam; Clinique St. Augustin, Bordeaux, France — O. Darremont, J. Leymarie; Centre Hospitalier Régional d'Orleans–Hôpital de la Source, Orleans, France — O. Dibon; Clinique Pasteur, Toulouse, France — J. Fajadet, B. Farah, B. Assoun; Centre Cardiologique du Nord, Saint Denis, France — P. Guyon, B. Chevalier; Clinique Victor Pauchet, Amiens, France — A. Py, E. Dadez; Centre Hospitalier Universitaire de Rennes, Rennes, France — H. Le Breton, M. Bedossa; Centre Hospitalier Universitaire Mulhouse, Mulhouse, France — L. Jacquemin, R. ElBelghit; Institut Hospitalier Jacques Cartier, Massy, France — M. Morice, T. Lefèvre; Centre Hospitalier Universitaire Avignon, Avignon, France — M. Pansieri, M. Metge; Clinique de la Casamance, Aubagne, France — B. Valeix; Clinique Médico-Chirurgicale Les Fontaines, Melun, France — P. Dupouy, E. Aptecar; Cardiovascular Center, Semmelweis University, Budapest, Hungary — B. Merkely, G. Szabó; Wolfson Medical Center, Holon, Israel — Y. Rozenman, V. Witzling; Assaf Harofeh Medical Center, Zrifin, Israel — R. Krakover, I. Zyssman; Soroka Medical Center, Beer Sheva, Israel — R. Ilia, C. Cafri; Souraski Medical Center, Tel Aviv, Israel — H. Miller, A. Finkelstein; Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy — E. Bramucci, M. Ferlini, U. Canosi; San Filippo Neri Hospital, Rome — G. Richichi, V. Pasceri; Azienda Ospedale Luigi Sacco, Milan — P. Viecca; Azienda Ospedaliera Careggi, Florence, Italy — M. Margheri, C. Giglioli; Pauls Stradins University Hospital, Riga, Latvia — A. Erglis; I. Narbute; University Medical Center Utrecht, Utrecht, the Netherlands — P. Stella; P. Elsman; Slaskie Centrum Chorób Serca, Zabrze, Poland — L. Poloński; Hospital Fernando Fonseca, Amadora, Portugal — P. Farto e Abreu; Hospital Garcia Orta, Almada, Portugal — H. Pereira; Hammersmith Hospital, London — K. Beatt; and Southampton General Hospital, Southampton, United Kingdom — K. Dawkins.

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    SUDHAKAR SATTUR, PAM ORSHAW, JUDY BOURA, KISHORE J. HARJAI. (2012) Long-Term Safety and Effectiveness of Drug-Eluting Stents Compared to Bare Metal Stents in ST Elevation Myocardial Infarction: Findings from the Guthrie Health Off-Label Stent (GHOST) Registry. Journal of Interventional Cardiologyno-no
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    Ryota Sakurai, Tsukasa Inajima, Hideaki Kaneda, Ryozo Nagai, Hideki Hashimoto. (2012) Sirolimus-eluting stents reduce long-term mortality compared with bare metal stents in ST-segment elevation myocardial infarction: A meta-analysis of randomized controlled trials. International Journal of Cardiology
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    Lisette Okkels Jensen, Michael Maeng, Per Thayssen, Hans Henrik Tilsted, Christian Juhl Terkelsen, Anne Kaltoft, Jens Flensted Lassen, Knud Nørregaard Hansen, Jan Ravkilde, Evald Høj Christiansen, Morten Madsen, Henrik Toft Sørensen, Leif Thuesen. (2011) Influence of Diabetes Mellitus on Clinical Outcomes Following Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction. The American Journal of Cardiology
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    Woong Chol Kang, Taehoon Ahn, Kyounghoon Lee, Seung Hwan Han, Eak Kyun Shin, Myung Ho Jeong, Jung Han Yoon, Jong Sun Park, Jang Ho Bae, Seung Ho Hur, Seung Woon Rha, Seok Kyu Oh, Doo Il Kim, Yangsoo Jang, Jae Woong Choi, Byung Ok Kim. (2011) Comparison of zotarolimus-eluting stents versus sirolimus-eluting stents versus paclitaxel-eluting stents for primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction: results from the Korean Multicentre Endeavor (KOMER) acute myocardial infarction (AMI) trial. EuroIntervention 7:8, 936-943
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    Manel Sabaté, Angel Cequier, Andrés Iñiguez, Antonio Serra, Rosana Hernández-Antolín, Vicente Mainar, Marco Valgimigli, Maurizio Tespili, Pieter den Heijer, Armando Bethencourt, Nicolás Vázquez, Salvatore Brugaletta, Bianca Backx, Patrick Serruys. (2011) Rationale and design of the EXAMINATION trial: a randomised comparison between everolimus-eluting stents and cobalt-chromium bare-metal stents in ST-elevation myocardial infarction. EuroIntervention 7:8, 977-984
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    , B. Scheller, B. Levenson, M. Joner, R. Zahn, V. Klauss, C. Naber, V. Schächinger, A. Elsässer. (2011) Medikamente freisetzende Koronarstents und mit Medikamenten beschichtete Ballonkatheter. Der Kardiologe
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    Michael Mahmoudi, Cedric Delhaye, Ron Waksman. (2011) Safety and efficacy of drug-eluting stents and bare metal stents in acute coronary syndrome. Cardiovascular Revascularization Medicine 12:6, 385-390
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    Joshua M. Stolker, David J. Cohen, Jason B. Lindsey, Kevin F. Kennedy, Neal S. Kleiman, Steven P. Marso. (2011) Mode of death after contemporary percutaneous coronary intervention: A report from the Evaluation of Drug Eluting Stents and Ischemic Events registry. American Heart Journal 162:5, 914-921
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    João Brito, Manuel Almeida, Rui Campante Teles, Pedro Sousa, João Abecasis, Rita Calé, Pedro Gonçalves, Luís Raposo, Miguel Mendes. (2011) Outcomes of drug-eluting stents compared to bare-metal stents in ST-segment elevation acute myocardial infarction. Revista Portuguesa de Cardiologia 30:11, 813-819
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    João Brito, Manuel Almeida, Rui Campante Teles, Pedro Sousa, João Abecasis, Rita Calé, Pedro Gonçalves, Luís Raposo, Miguel Mendes. (2011) Outcomes of drug-eluting stents compared to bare-metal stents in ST-segment elevation acute myocardial infarction. Revista Portuguesa de Cardiologia (English Edition) 30:11, 813-819
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    So-Yeon Choi, Akiko Maehara, Ecaterina Cristea, Bernhard Witzenbichler, Giulio Guagliumi, Bruce Brodie, Mirle A. Kellett, Ovidiu Dressler, Alexandra J. Lansky, Helen Parise, Roxana Mehran, Gary S. Mintz, Gregg W. Stone. (2011) Usefulness of Minimum Stent Cross Sectional Area as a Predictor of Angiographic Restenosis After Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction (from the HORIZONS-AMI Trial IVUS Substudy). The American Journal of Cardiology
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    Emilio Lorenzo, Giannignazio Carbone, Luigi Sauro, Alfredo Casafina, Michele Capasso, Rosario Sauro. (2011) Bare-Metal Stents Versus Drug-Eluting Stents for Primary Angioplasty: Long-Term Outcome. Current Cardiology Reports 13:5, 459-464
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    Daria Mochly-Rosen, Kevin V. Grimes. (2011) Myocardial salvage in acute myocardial infarction - Challenges in clinical translation. Journal of Molecular and Cellular Cardiology 51:4, 451-453
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    PEDRO BERALDO DE ANDRADE, MARDEN ANDRÉ TEBET, FELIPE SOUZA MAIA DA SILVA, MÔNICA VIEIRA ATHANAZIO DE ANDRADE, ANDRÉ LABRUNIE, LUIZ ALBERTO PIVA E MATTOS. (2011) Drug-Eluting Stents during ST-Segment Elevation Acute Myocardial Infarction: A Critical Analysis. Journal of Interventional Cardiology 24:5, 416-423
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    Georgios Sideris, Sebastian Voicu, Jean Guillaume Dillinger, Victor Stratiev, Damien Logeart, Claire Broche, Benoit Vivien, Pierre-Yves Brun, Nicolas Deye, Dragos Capan, Mounir Aout, Bruno Megarbane, Frédéric J. Baud, Patrick Henry. (2011) Value of post-resuscitation electrocardiogram in the diagnosis of acute myocardial infarction in out-of-hospital cardiac arrest patients. Resuscitation 82:9, 1148-1153
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    A. Schwindt, G. Pannuccio, K. Donas, G. Torsello. (2011) Wertigkeit der Drug-eluting Stents im Bereich der femorodistalen Arterien. Gefässchirurgie 16:5, 310-316
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    Etienne Puymirat, Fabio Mangiacapra, Aaron Peace, Faisal Sharif, Micaela Conte, Jozef Bartunek, Marc Vanderheyden, William Wijns, Bernard de Bruyne, Emanuele Barbato. (2011) Long-term clinical outcome in patients with small vessel disease treated with drug-eluting versus bare-metal stenting. American Heart Journal
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    Giovanni Amoroso, Robert-Jan van Geuns, Christian Spaulding, Stephane Manzo-Silberman, Karl E. Hauptmann, René Spaargaren, Héctor M. García-García, Patrick W. Serruys, Stefan Verheye. (2011) Assessment of the safety and performance of the STENTYS self-expanding coronary stent in acute myocardial infarction: results from the APPOSITION I study. EuroIntervention 7:4, 428-436
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    RHIDIAN J. SHELTON, KAMAL CHITKARA, RAVI SINGH, MICHA F. DORSCH, KATHRYN SOMERS, JAMES M. MCLENACHAN, JONATHAN M. BLAXILL, STEPHEN B. WHEATCROFT, DANIEL J. BLACKMAN, JOHN P. GREENWOOD. (2011) Three-Year Clinical Outcome with the Endeavor™ Zotarolimus-Eluting Stent in Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction: The Endeavor™ Primary PCI Study (E-PPCI). Journal of Interventional Cardiologyno-no
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    Raffaele Piccolo, Salvatore Cassese, Gennaro Galasso, Roberta De Rosa, Carolina D’Anna, Federico Piscione. (2011) Long-term safety and efficacy of drug-eluting stents in patients with acute myocardial infarction: A meta-analysis of randomized trials. Atherosclerosis 217:1, 149-157
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    Edward L. Hannan, Zaza Samadashvili, Gary Walford, David R. Holmes, Alice K. Jacobs, Nicholas J. Stamato, Ferdinand J. Venditti, Samin Sharma, Icilma Fergus, Spencer B. King. (2011) Comparison of Outcomes for Patients Receiving Drug-Eluting Versus Bare Metal Stents for Non–ST-Segment Elevation Myocardial Infarction. The American Journal of Cardiology 107:9, 1311-1318
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    Birgit Hailer, Christoph Naber, Bernd Koslowski, Peter van Leeuwen, Harald Schäfer, Thomas Budde, Rainer Jacksch, Georg Sabin, Raimund Erbel, . (2011) Gender-Related Differences in Patients With ST-Elevation Myocardial Infarction: Results From the Registry Study of the ST Elevation Myocardial Infarction Network Essen. Clinical Cardiology 34:5, 294-301
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    Neil Swanson, Anthony Gershlick. 2011. Primary and Rescue PCI in Acute Myocardial Infarction. , 242-261.
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    Raul Moreno, Roberto Martin-Reyes, Santiago Jimenez-Valero, Angel Sanchez-Recalde, Guillermo Galeote, Luis Calvo, Ignacio Plaza, Jose-Luis Lopez-Sendon. (2011) Determining clinical benefits of drug-eluting coronary stents according to the population risk profile: A meta-regression from 31 randomized trials. International Journal of Cardiology 148:1, 23-29
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    Alessandro Sciahbasi, Gianluca Pendenza, Enrico Romagnoli, Francesco Summaria, Roberto Patrizi, Valerio Lucci, Maria Benedetta Giannico, Maria Penco, Ernesto Lioy. (2011) The PREHAMI (PREsillion™ in high-risk acute myocardial infarction) registry. Catheterization and Cardiovascular Interventions 77:5, 608-614
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    Asmir Syed, Itsik Ben-Dor, Yanlin Li, Sara Collins, Rebecca Torguson, Kohei Wakabayashi, Manuel Gonzalez, Gabriel Maluenda, Cedric Delhaye, Loic Belle, Michael Gaglia, Zhenyi Xue, Kimberly Kaneshige, Nelson Bernardo, Kenneth Kent, William Suddath, Lowell Satler, Augusto Pichard, Joseph Lindsay, Ron Waksman. (2011) Hybrid strategy of a bare metal stent combined with a drug-eluting stent versus exclusive drug-eluting stent implantation for multivessel percutaneous coronary intervention. EuroIntervention 6:9, 1085-1090
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    Philip Urban, Alexandre Abizaid, Adrian Banning, Antonio L. Bartorelli, Ana Cebrian Baux, Vladimír Džavík, Stephen Ellis, Runlin Gao, David Holmes, Myung Ho Jeong, Victor Legrand, Franz-Josef Neumann, Maria Nyakern, Christian Spaulding, Stephen Worthley. (2011) Stent Thrombosis and Bleeding Complications After Implantation of Sirolimus-Eluting Coronary Stents in an Unselected Worldwide Population. Journal of the American College of Cardiology 57:13, 1445-1454
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    Hyun-Sook Kim, Jae-Hwan Lee, Seung-Whan Lee, Young-Hak Kim, Jae-Hyeong Park, Si-Wan Choi, Jin-Ok Jeong, In-Whan Seong, Kyoung-Suk Rhee, Jae-Ki Ko, Sang-Ho Jo, Young Jin Choi. (2011) Long-term safety and efficacy of sirolimus- vs. paclitaxel-eluting stent implantation for acute ST-elevation myocardial infarction: 3-year follow-up of the PROSIT trial. International Journal of Cardiology 147:2, 253-257
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    Pow-Li Chia, Arul Earnest, Jimmy Lim. (2011) Biolimus-eluting biodegradable polymer-coated stent versus bare metal stent in acute ST-elevation and non-ST elevation myocardial infarction: Justification for biodegradable polymer-coated stent in acute coronary syndrome (JANICE) registry. Acute Cardiac Care 13:1, 43-47
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    Min Goo Lee, Myung Ho Jeong, Youngkeun Ahn, Jeong Gwan Cho, Jong Chun Park, Jung Chaee Kang, Shung Chull Chae, Seung Ho Hur, Taek Jong Hong, Young Jo Kim, In Whan Seong, Jei Keon Chae, Jay Young Rhew, In Ho Chae, Myeong Chan Cho, Jang Ho Bae, Seung Woon Rha, Chong Jin Kim, Donghoon Choi, Yang Soo Jang, Junghan Yoon, Wook Sung Chung, Ki Bae Seung, Seung Jung Park. (2011) Comparison of Paclitaxel-, Sirolimus-, and Zotarolimus-Eluting Stents in Patients With Acute ST-Segment Elevation Myocardial Infarction and Metabolic Syndrome. Circulation Journal 75:9, 2120-2127
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    Doo Sun Sim, Myung Ho Jeong, Youngkeun Ahn, Young Jo Kim, Shung Chull Chae, Taek Jong Hong, In Whan Seong, Jei Keon Chae, Chong Jin Kim, Myeong Chan Cho, Ki Bae Seung, Seung Jung Park, . (2011) Effectiveness of Drug-Eluting Stents versus Bare-Metal Stents in Large Coronary Arteries in Patients with Acute Myocardial Infarction. Journal of Korean Medical Science 26:4, 521
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    Kentaro Ejiri, Masaharu Ishihara, Kazuoki Dai, Takashi Miki, Ichiro Inoue, Takuji Kawagoe, Yuji Shimatani, Fumiharu Miura, Yasuharu Nakama, Takayuki Otani, Hiroki Ikenaga, Nozomu Oda, Masayuki Nakamura. (2011) Three-Year Follow-up of Sirolimus-Eluting Stents vs. Bare Metal Stents for Acute Myocardial Infarction. Circulation Journal
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    ANGELA MIGLIORINI, RENATO VALENTI, GUIA MOSCHI, GUIDO PARODI, GIAMPAOLO CERISANO, PIERGIOVANNI BUONAMICI, NAZARIO CARRABBA, DAVID ANTONIUCCI. (2010) Predictor of Stent Thrombosis in Patients Treated with Turbostratic Carbon-Coated Stent Implantation for Acute Myocardial Infarction. Journal of Interventional Cardiology 23:6, 554-559
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    Masami Nishino, Shiro Hoshida, Masayuki Taniike, Hiroyasu Kato, Yasuyuki Egami, Ryu Shutta, Hitoshi Yamaguchi, Kenjiro Tanaka, Jun Tanouchi, Yoshio Yamada. (2010) Vulnerable disease may induce neointimal coverage after silorimus-eluting stent implantation. American Heart Journal 160:3, 564-569
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    R. Gurvitch, J. Lefkovits, R.J. Warren, S.J. Duffy, D.J. Clark, D. Eccleston, B.P. Yan, C. Reid, A. Brennan, N. Andrianopoulos, A.E. Ajani. (2010) Clinical outcomes of drug-eluting stent use in patients with ST elevation myocardial infarction. International Journal of Cardiology 143:3, 283-288
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    Michael S. Lee, Pooya Bokhoor, Seung-Jung Park, Young-Hak Kim, Gregg W. Stone, Imad Sheiban, Giuseppe Biondi-Zoccai, Dario Sillano, Jonathan Tobis, David E. Kandzari. (2010) Unprotected Left Main Coronary Disease and ST-Segment Elevation Myocardial Infarction. JACC: Cardiovascular Interventions 3:8, 791-795
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