Costs aren’t discussed. The article gives the absolute rates of major adverse cardiac events for each treatment group. Also, while this is likely not a major issue for most readers and not an official strike against the article, as an FYI we point out that there are some interwoven concepts that can be confusing. The article’s headline is that SES won this contest. If you want to get technical, there are two buts. First, while SES did have the fewest cardiac events of the 3 stents, the difference with ZES wasn’t statistically significant. In other words, the apparent superiority of SES may have been do to chance. Or not. We don’t know. Researchers call this a trend but not significant evidence. Second, this contest, the study, wasn’t designed to answer whether SES was the best. The researchers concluded, as quoted in the story, that this study answered two main questions: ZES and SES were similar, and ZES fared better than PES did. Notice it didn’t say SES was the best. There’s overlap between harms and benefits here because stents are designed to prevent harm. However, the study identifies the development of blood clots on the stent as a safety outcome (along with the numbers of heart attacks and death). While the article tells us that the rate of clots was significantly lower with one type of stent, it does not quantify the harms. There are some valuable details about the study in this article, including the number of subjects, the 3 treatment arms, randomization, the follow-up period, a definition of the endpoint—a composite called “major adverse cardiac events”—and what actual events that means. It gets kudos for identifying the key limitation of the one-year follow-up with a nod to important results from a longer ongoing study. There were some aspects of the evidence missing, which is not surprising in a short article about a fantastically complex topic. In a quote the researchers laud their study as a “practical” one. We’re not told what that means. And see our comment under Benefits regarding the explanation of the results. Also, an article of this length doesn’t have the real estate to go into all the nooks and crannies (and limitations) of composite endpoints, like MACE, which are very standard in such trials. But we appreciated that the author unpacked it a bit by noting that rates of death and heart attacks did not differ. We give the article a Satisfactory rating because, in this very focused and balanced review, it doesn’t balloon the target population for drug-coated stents. That said, we would’ve liked to have seen at least some overview of who is a candidate for stents at all, bare or coated. Not everyone with a clogged artery gets stents, or, rather, should get stents based on the evidence. It’s a complex topic, with different guidelines for those having heart attacks and those with stable angina, but it’s also a hot topic these days due to widespread misconceptions about who gets stents and what benefits they actually have. Recent evidence, such as the COURAGE trial, suggests that for most people with stable angina, stents don’t prevent heart attacks or improve survival compared to only taking medicine and leading a heart-healthy lifestyle. One source, Dr. Fonarow, was apparently not affiliated with the study. We appreciated his placing the results in context with prior research and on clinical decision-making. Google tells us that he has a financial relationship with the company that makes zotarolimus-coated stents. But given the fact that his quotes—and the study—are not in favor of zotarolimus, perhaps the lack of this disclosure is excusable. One key conflict of interest, study funding from a stent manufacturer, was identified. However, we fail the article on this criterion because it neglects to mention that the researchers disclosed a web of financial relationships with literally all the stent manufacturers. We count 9 financial relationships with Cordis, who makes the sirolimus-coated stent, which came out “on top” in this article. Taking into account that the article implies availability of the 3 stent types, the study itself was comparing a newer approach with the “old standby.” The article could’ve been more explicit about the availability of these 3 stents, but the last sentence describing the study’s real-world implications, suggests that all 3 are currently available in cath labs. The article explains that the three stents are coated with different drugs, the zotarolimus version is a newer entry, while the sirolimus one is the “old standby”. It would’ve been nice to read how the stent with paclitaxel fits into the big picture.
In Test of Stents, Old Standby Wins Out