columbia / crf des vs. bms meta-analysis
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Columbia / CRFColumbia / CRFDES vs. BMS Meta-AnalysisDES vs. BMS Meta-Analysis
Kirtane et al, Circ 2009;119: 3198-3206
DES Studies: Data SynthesisDES Studies: Data Synthesis
• In order to synthesize the existing data, we In order to synthesize the existing data, we performed a systematic review and meta-performed a systematic review and meta-analysis of all DES vs. BMS studies through analysis of all DES vs. BMS studies through 2/082/08 To derive summary estimates of all-cause To derive summary estimates of all-cause
mortality, MI, and TVR in studies with ≥1 year of mortality, MI, and TVR in studies with ≥1 year of follow-upfollow-up
To specifically assess differences between on-To specifically assess differences between on-label / off-label use, and between RCT and label / off-label use, and between RCT and observational dataobservational data
Kirtane et al, Circ 2009;119: 3198-3206
Methods: Inclusion CriteriaMethods: Inclusion Criteria
• English language RCTs or registries which English language RCTs or registries which reported a reported a direct comparison direct comparison of DES of DES (commercialized formulations of SES and PES (commercialized formulations of SES and PES only) vs. BMS up through February 2008only) vs. BMS up through February 2008
• Criteria for each study: Criteria for each study:
≥≥100 patients total100 patients total
Mortality reported (± MI and/or TVR)Mortality reported (± MI and/or TVR)
≥≥1 year of 1 year of cumulativecumulative follow-up reported, follow-up reported, with the outcome assessed at the same time with the outcome assessed at the same time point in both comparator armspoint in both comparator arms
Kirtane et al, Circ 2009;119: 3198-3206
Study Flow DiagramStudy Flow DiagramPubmed search thru 2/08: stent AND bare AND (eluting OR sirolimus OR paclitaxel)
834 articles
221 review articles or editorials115 no/unclear clinical outcomes described 104 sub-studies/more recent papers
81 no BMS/DES comparison100 basic science or non-approved device
84 with <1 year f/u or <100 pts 92 case reports, meta-analyses, non-coronary studies, or other
56 studies EuroIntervention search (146 articles)
3 articles
met criteria
AHA (3/246), TCT (9/206), ESC (4/243), ACC (0/468) abstracts and
reference searches
16 abstracts
met criteria
RCT studies: 22 (9,470 patients)
Registry studies: 34 (182,901 patients)
37 articles
Kirtane et al, Circ 2009;119: 3198-3206
All-Cause Mortality: All RCTsAll-Cause Mortality: All RCTs
I-V Overall (I-squared = 0.0%, p = 0.918)
BASKET (SES only)
TAXUS II
HAAMU-STENTSeville
Ortolani et al
TAXUS IV
E-SIRIUS
Study ID
DIABETES
PRISON II
STRATEGY
RAVEL
SES-SMART
TAXUS V
Typhoon
MISSION!
SCORPIUSSESAMI
D+L Overall
Passion
C-SIRIUS
Pache et al
SIRIUS
0.97 (0.81, 1.15)
0.82 (0.37, 1.84)
1.61 (0.57, 4.53)
2.00 (0.63, 6.38)1.35 (0.23, 7.78)
2.00 (0.19, 21.38)
0.89 (0.63, 1.25)
1.08 (0.25, 2.24)
ES (95% CI)
1.44 (0.48, 4.33)
0.50 (0.09, 2.67)
0.84 (0.36, 1.96)
1.75 (0.73, 4.16)
0.21 (0.02, 1.71)
0.97 (0.57, 1.65)
1.01 (0.38, 2.65)
0.48 (0.09, 2.59)
1.28 (0.35, 4.61)0.43 (0.11, 1.63)
0.97 (0.81, 1.15)
0.70 (0.36, 1.36)
0.68 (0.11, 4.04)
1.40 (0.45, 4.35)
1.02 (0.67, 1.54)
100.00
4.80
2.87
2.301.00
0.55
26.29
2.57
(I-V)
2.55
1.07
4.30
4.08
0.62
10.92
3.27
1.09
Weight
1.861.70
6.99
0.95
2.40
17.82
%
0.97 (0.81, 1.15)
0.82 (0.37, 1.84)
1.61 (0.57, 4.53)
2.00 (0.63, 6.38)1.35 (0.23, 7.78)
2.00 (0.19, 21.38)
0.89 (0.63, 1.25)
1.08 (0.25, 2.24)
ES (95% CI)
1.44 (0.48, 4.33)
0.50 (0.09, 2.67)
0.84 (0.36, 1.96)
1.75 (0.73, 4.16)
0.21 (0.02, 1.71)
0.97 (0.57, 1.65)
1.01 (0.38, 2.65)
0.48 (0.09, 2.59)
1.28 (0.35, 4.61)0.43 (0.11, 1.63)
0.97 (0.81, 1.15)
0.70 (0.36, 1.36)
0.68 (0.11, 4.04)
1.40 (0.45, 4.35)
1.02 (0.67, 1.54)
100.00
4.80
2.87
2.301.00
0.55
26.29
2.57
(I-V)
2.55
1.07
4.30
4.08
0.62
10.92
3.27
1.09
Weight
1.861.70
6.99
0.95
2.40
17.82
%
1.1 1 10
8,867 patients, 21 trials, mean F/U 2.9 years8,867 patients, 21 trials, mean F/U 2.9 years
Favors BMS
Estimate (95% CI) Weight (%)
0.97 (0.81,1.15)0.97 (0.81,1.15), p=0.72
Random Effects*Fixed Effects (I2=0.0%)
Favors DES
Kirtane et al, Circ 2009;119: 3198-3206
All-Cause Mortality: RCT’s (Off-Label)All-Cause Mortality: RCT’s (Off-Label)
I-V Overall (I-squared = 0.0%, p = 0.798)
HAAMU-STENT
Passion
PRISON II
MISSION!
DIABETES
BASKET (SES only)
Seville
D+L Overall
SES-SMART
STRATEGY
TAXUS V - complex
Study ID
SESAMI
Typhoon
0.84 (0.62, 1.13)
2.00 (0.63, 6.38)
0.70 (0.36, 1.36)
0.50 (0.09, 2.67)
0.48 (0.09, 2.59)
1.44 (0.48, 4.33)
0.82 (0.37, 1.84)
1.35 (0.23, 7.78)
0.84 (0.62, 1.13)
0.21 (0.02, 1.71)
0.84 (0.36, 1.96)
0.84 (0.38, 1.84)
ES (95% CI)
0.43 (0.11, 1.63)
1.01 (0.38, 2.65)
100.00
6.64
20.16
Weight
3.10
3.16
7.36
13.84
%
2.87
1.80
12.40
14.32
(I-V)
4.90
9.44
1.1 1 10
4,049 patients, 12 trials, mean F/U 1.5 years4,049 patients, 12 trials, mean F/U 1.5 years
Favors DES Favors BMS
Estimate (95% CI) Weight (%)
0.84 (0.62,1.13)
0.84 (0.62,1.13), p=0.24
Random Effects
*Fixed Effects (I2=0.0%)
Kirtane et al, Circ 2009;119: 3198-3206
MI: All RCTsMI: All RCTs8,850 patients, 20 trials , mean F/U 2.9 years8,850 patients, 20 trials , mean F/U 2.9 years
D+L Overall (I-squared = 3.0%, p = 0.420)I-V Overall
SCORPIUS
TAXUS II
PRISON II
TAXUS V
Passion
STRATEGY
MISSION!
Typhoon
SIRIUS
TAXUS IV
BASKET (All)
RAVEL
Ortolani et alDIABETES
HAAMU-STENT
Study ID
E-SIRIUS
SES-SMART
SCANDSTENT
SESAMI
C-SIRIUS
1.1 1 10
I-V Overall (I-squared = 3.0%, p = 0.420)
SESAMI
Passion
C-SIRIUS
RAVEL
TAXUS IV
TAXUS V
SCORPIUS
SIRIUS
DIABETES
MISSION!
E-SIRIUS
SCANDSTENT
Study ID
Ortolani et al
SES-SMARTSTRATEGY
HAAMU-STENT
BASKET (All)
Typhoon
TAXUS II
PRISON II
D+L Overall
0.94 (0.79, 1.13)
1.00 (0.20, 4.88)
0.83 (0.26, 2.69)
0.59 (0.14, 2.47)
1.24 (0.49, 3.14)
0.99 (0.66, 1.48)
1.27 (0.79, 2.04)
0.82 (0.23, 2.95)
0.96 (0.59, 1.55)
0.60 (0.20, 1.50)
0.62 (0.28, 1.39)
1.94 (0.93, 4.02)
0.33 (0.09, 1.18)
ES (95% CI)
1.50 (0.26, 8.61)
0.16 (0.04, 0.67)0.82 (0.31, 2.40)
0.25 (0.03, 2.19)
1.15 (0.64, 2.08)
0.80 (0.22, 2.97)
0.63 (0.23, 1.72)
0.83 (0.26, 2.64)
0.94 (0.78, 1.13)
100.00
1.29
2.40
1.59
3.80
20.13
Weight
14.59
2.02
14.07
3.23
5.11
6.13
%
1.98
(I-V)
1.07
1.653.13
0.71
9.45
1.94
3.24
2.44
1.1 1 10
Estimate (95% CI) Weight (%)
0.94 (0.78,1.13)0.95 (0.79,1.13), p=0.54
Favors DES Favors BMS
Random Effects*Fixed Effects (I2=3.0%)
Kirtane et al, Circ 2009;119: 3198-3206
MI: RCT’s (Off Label)MI: RCT’s (Off Label)4,532 patients, 12 trials , mean F/U 1.5 years4,532 patients, 12 trials , mean F/U 1.5 years
1.1 1 10
I-V Overall (I-squared = 25.5%, p = 0.194)
SCANDSTENT
HAAMU-STENT
Typhoon
D+L Overall
SES-SMART
PRISON II
TAXUS V - complex
Passion
Study ID
STRATEGY
MISSION!
SESAMI
BASKET (All)
DIABETES
0.83 (0.62, 1.10)
0.33 (0.09, 1.18)
0.25 (0.03, 2.19)
0.80 (0.22, 2.97)
0.77 (0.54, 1.10)
0.16 (0.04, 0.67)
0.83 (0.26, 2.64)
1.84 (0.86, 3.94)
0.83 (0.26, 2.69)
ES (95% CI)
0.82 (0.31, 2.40)
0.62 (0.28, 1.39)
1.00 (0.20, 4.88)
1.15 (0.64, 2.08)
0.60 (0.20, 1.50)
100.00
5.08
1.83
4.97
4.24
Weight
6.26
%
14.52
6.16
(I-V)
8.03
13.11
3.30
24.22
8.29
1.1 1 10
Estimate (95% CI) Weight (%)
I-V Overall (I-squared = 25.5%, p = 0.194)
SCANDSTENT
HAAMU-STENT
Typhoon
D+L Overall
SES-SMART
PRISON II
TAXUS V - complex
Passion
Study ID
STRATEGY
MISSION!
SESAMI
BASKET (All)
DIABETES
0.83 (0.62, 1.10)
0.33 (0.09, 1.18)
0.25 (0.03, 2.19)
0.80 (0.22, 2.97)
0.77 (0.54, 1.10)
0.16 (0.04, 0.67)
0.83 (0.26, 2.64)
1.84 (0.86, 3.94)
0.83 (0.26, 2.69)
ES (95% CI)
0.82 (0.31, 2.40)
0.62 (0.28, 1.39)
1.00 (0.20, 4.88)
1.15 (0.64, 2.08)
0.60 (0.20, 1.50)
100.00
5.08
1.83
4.97
4.24
Weight
6.26
%
14.52
6.16
(I-V)
8.03
13.11
3.30
24.22
8.29
1.1 1 10Favors DES Favors BMS
0.77 (0.54,1.10)
0.83 (0.62,1.10), p=0.19
Random Effects
*Fixed Effects (I2=25.5%)
Kirtane et al, Circ 2009;119: 3198-3206
TVR: All RCTsTVR: All RCTs
NOTE: Weights are from random effects analysis
D+L Overall (I-squared = 53.2%, p = 0.006)
Pache et al
Study ID
HAAMU-STENT
C-SIRIUS
Typhoon
STRATEGY
SIRIUS
SCANDSTENT
TAXUS II
PRISON II
TAXUS IV
E-SIRIUS
MISSION!
Ortolani et al
SESAMI
I-V Overall
TAXUS V
RAVEL
0.45 (0.37, 0.54)
0.38 (0.23, 0.64)
ES (95% CI)
0.33 (0.09, 1.19)
0.30 (0.10, 0.93)
0.42 (0.25, 0.69)
0.34 (0.16, 0.77)
0.48 (0.37, 0.62)
0.17 (0.09, 0.33)
0.61 (0.35, 1.08)
0.37 (0.19, 0.69)
0.57 (0.45, 0.72)
0.35 (0.21, 0.56)
0.38 (0.17, 0.85)
0.58 (0.25, 1.36)
0.36 (0.17, 0.79)
0.51 (0.45, 0.57)
0.77 (0.60, 0.98)
0.51 (0.25, 1.04)
100.00
7.14
(D+L)
1.91
2.45
7.20
4.22
11.51
5.44
%
6.44
5.49
11.94
Weight
7.45
4.08
3.78
4.36
11.75
4.83
1.1 1 10
7,291 patients, 16 trials , mean F/U 3.2 years7,291 patients, 16 trials , mean F/U 3.2 years
Favors DES Favors BMS
Estimate (95% CI) Weight (%)
0.45 (0.37,0.54), p<0.0010.51 (0.45,0.57)
*Random Effects (I2=53.2%)Fixed Effects
Kirtane et al, Circ 2009;119: 3198-3206
TVR: RCTs (Off Label)TVR: RCTs (Off Label)
NOTE: Weights are from random effects analysis
D+L Overall (I-squared = 47.8%, p = 0.063)
Typhoon
Study ID
STRATEGY
SCANDSTENT
TAXUS V - complex
I-V Overall
HAAMU-STENT
SESAMI
MISSION!
PRISON II
0.38 (0.27, 0.52)
0.42 (0.25, 0.69)
ES (95% CI)
0.34 (0.16, 0.77)
0.17 (0.09, 0.33)
0.62 (0.44, 0.86)
0.42 (0.34, 0.52)
0.33 (0.09, 1.19)
0.36 (0.17, 0.79)
0.38 (0.17, 0.85)
0.37 (0.19, 0.69)
100.00
16.43
(D+L)
10.35
12.95
21.55
%
4.98
10.65
10.04
Weight
13.06
1.1 1 10
2,673 patients, 8 trials , mean F/U 1.6 years2,673 patients, 8 trials , mean F/U 1.6 years
Favors DES Favors BMS
Estimate (95% CI) Weight (%)
0.38 (0.27,0.52), p<0.001
0.42 (0.34,0.52)
*Random Effects (I2=47.8%)
Fixed Effects
Kirtane et al, Circ 2009;119: 3198-3206
TVR: RCTsTVR: RCTsMeta-Regression on Percent Angiographic F/UMeta-Regression on Percent Angiographic F/U
*log(HR) regressed on percentage of pts with angiographic *log(HR) regressed on percentage of pts with angiographic f/u; figure displayed on exponentiated scalef/u; figure displayed on exponentiated scale
.2.4
.6.8
20 40 60 80 100perangfu
tvr_hr Fitted values
p=0.73
*Haz
ard
Rat
io
Percentage of Patients with Angiographic F/U
NOTE: Weights are from random effects analysis
D+L Overall (I-squared = 70.9%, p = 0.000)
Asan Korea (adjusted)
SMART
Melbourne
Massachusetts (matched)
Washington Hosp Center (matched)
Multicenter SVG (adjusted)
I-V Overall
Rotterdam Off-Label
STENT (adjusted)
ACUITY (from RCT)
REAL (adjusted)
Liverpool (matched)
Wake Forest (adjusted)
Mayo FFR Substudy
Cedars Acute MI
GHOST (adjusted)
Sussex ElderlyERACI III (from RCT)
NY State (adjusted, unmatched)
Ontario (matched)
Study ID
MIDAS (adjusted)
RESTEM
McMaster STEMI (adjusted)
Germany Metabolic Syndrome
Western Denmark (adjusted)
ARTS II (from RCT)
DEScover (unadjusted)
Northern New England (adjusted)
SCAAR (adjusted)
Italian Diabetic Multivessel (adjusted)
NHLBI (off label, adjusted)NHLBI (on label, adjusted)
0.78 (0.71, 0.86)
0.60 (0.46, 0.79)
0.59 (0.48, 0.71)
0.67 (0.23, 1.94)
0.79 (0.71, 0.89)
1.16 (0.78, 1.75)
1.33 (0.47, 3.76)
0.81 (0.78, 0.85)
0.98 (0.85, 1.13)
0.69 (0.55, 0.87)
0.63 (0.49, 0.82)
0.83 (0.70, 0.98)
0.45 (0.24, 0.84)
0.72 (0.55, 0.95)
1.00 (0.21, 4.75)
0.82 (0.37, 1.83)
0.55 (0.36, 0.83)
0.72 (0.30, 1.72)1.18 (0.54, 2.58)
0.84 (0.72, 0.97)
0.71 (0.59, 0.84)
ES (95% CI)
0.66 (0.59, 0.74)
0.73 (0.51, 1.05)
0.17 (0.03, 0.97)
1.47 (0.65, 3.35)
1.00 (0.86, 1.17)
0.74 (0.41, 1.35)
0.53 (0.35, 0.80)
0.51 (0.26, 1.00)
1.03 (0.94, 1.14)
1.22 (0.36, 4.10)
0.94 (0.64, 1.38)1.47 (0.87, 2.48)
100.00
Weight
4.35
5.23
0.71
6.15
3.02
0.74
5.85
4.83
4.50
5.55
1.70
%
4.31
0.35
1.16
2.91
1.001.20
5.77
5.46
(D+L)
6.14
3.40
0.28
1.11
5.72
1.83
2.95
1.53
6.30
0.56
3.192.20
0.78 (0.71, 0.86)
0.60 (0.46, 0.79)
0.59 (0.48, 0.71)
0.67 (0.23, 1.94)
0.79 (0.71, 0.89)
1.16 (0.78, 1.75)
1.33 (0.47, 3.76)
0.81 (0.78, 0.85)
0.98 (0.85, 1.13)
0.69 (0.55, 0.87)
0.63 (0.49, 0.82)
0.83 (0.70, 0.98)
0.45 (0.24, 0.84)
0.72 (0.55, 0.95)
1.00 (0.21, 4.75)
0.82 (0.37, 1.83)
0.55 (0.36, 0.83)
0.72 (0.30, 1.72)1.18 (0.54, 2.58)
0.84 (0.72, 0.97)
0.71 (0.59, 0.84)
ES (95% CI)
0.66 (0.59, 0.74)
0.73 (0.51, 1.05)
0.17 (0.03, 0.97)
1.47 (0.65, 3.35)
1.00 (0.86, 1.17)
0.74 (0.41, 1.35)
0.53 (0.35, 0.80)
0.51 (0.26, 1.00)
1.03 (0.94, 1.14)
1.22 (0.36, 4.10)
0.94 (0.64, 1.38)1.47 (0.87, 2.48)
100.00
Weight
4.35
5.23
0.71
6.15
3.02
0.74
5.85
4.83
4.50
5.55
1.70
%
4.31
0.35
1.16
2.91
1.001.20
5.77
5.46
(D+L)
6.14
3.40
0.28
1.11
5.72
1.83
2.95
1.53
6.30
0.56
3.192.20
1.1 1 10
All-Cause Mortality: All RegistriesAll-Cause Mortality: All Registries169,595 patients, 31 registries, mean F/U 2.5 years169,595 patients, 31 registries, mean F/U 2.5 years
Favors BMS
Estimate (95% CI) Weight (%)
0.78 (0.71,0.86), p<0.0010.81 (0.78,0.85)
Favors DES
*Random Effects (I2=71%)Fixed Effects
Kirtane et al, Circ 2009;119: 3198-3206
NOTE: Weights are from random effects analysis
D+L Overall (I-squared = 75.9%, p = 0.000)
Northern New England (adjusted)
GHOST (adjusted)
I-V Overall
Multicenter SVG (adjusted)
NY State (adjusted, unmatched)
STENT (adjusted)
Western Denmark (adjusted)
Liverpool (matched)
Wake Forest (adjusted)
REAL (adjusted)
Study ID
Massachusetts (matched)
Italian Diabetic Multivessel (adjusted)
MIDAS (adjusted)
Asan Korea (adjusted)
NHLBI (on label, adjusted)
McMaster STEMI (adjusted)
Ontario (matched)
Washington Hosp Center (matched)
NHLBI (off label, adjusted)
SCAAR (adjusted)
0.79 (0.71, 0.89)
0.51 (0.26, 1.00)
0.55 (0.36, 0.83)
0.82 (0.79, 0.86)
1.33 (0.47, 3.76)
0.84 (0.72, 0.97)
0.69 (0.55, 0.87)
1.00 (0.86, 1.17)
0.45 (0.24, 0.84)
0.72 (0.55, 0.95)
0.83 (0.70, 0.98)
ES (95% CI)
0.79 (0.71, 0.89)
1.22 (0.36, 4.10)
0.66 (0.59, 0.74)
0.60 (0.46, 0.79)
1.47 (0.87, 2.48)
0.17 (0.03, 0.97)
0.71 (0.59, 0.84)
1.16 (0.78, 1.75)
0.94 (0.64, 1.38)
1.03 (0.94, 1.14)
100.00
2.15
4.11
1.04
8.18
%
6.83
8.10
2.40
6.09
7.86
(D+L)
8.71
0.78
8.71
6.14
3.10
0.40
Weight
7.72
4.26
4.50
8.93
0.79 (0.71, 0.89)
0.51 (0.26, 1.00)
0.55 (0.36, 0.83)
0.82 (0.79, 0.86)
1.33 (0.47, 3.76)
0.84 (0.72, 0.97)
0.69 (0.55, 0.87)
1.00 (0.86, 1.17)
0.45 (0.24, 0.84)
0.72 (0.55, 0.95)
0.83 (0.70, 0.98)
ES (95% CI)
0.79 (0.71, 0.89)
1.22 (0.36, 4.10)
0.66 (0.59, 0.74)
0.60 (0.46, 0.79)
1.47 (0.87, 2.48)
0.17 (0.03, 0.97)
0.71 (0.59, 0.84)
1.16 (0.78, 1.75)
0.94 (0.64, 1.38)
1.03 (0.94, 1.14)
100.00
2.15
4.11
1.04
8.18
%
6.83
8.10
2.40
6.09
7.86
(D+L)
8.71
0.78
8.71
6.14
3.10
0.40
Weight
7.72
4.26
4.50
8.93
1.1 1 10
All-Cause Mortality: Adjusted RegistriesAll-Cause Mortality: Adjusted Registries136,558 patients, 19 registries , mean F/U 2.7 years136,558 patients, 19 registries , mean F/U 2.7 years
Favors BMS
Estimate (95% CI) Weight (%)
0.79 (0.71,0.89), p<0.0010.82 (0.79,0.86)
Favors DES
*Random Effects (I2=76%)Fixed Effects
Kirtane et al, Circ 2009;119: 3198-3206
NOTE: Weights are from random effects analysis
D+L Overall (I-squared = 60.3%, p = 0.000)
RESTEM
Ontario (matched)
Western Denmark (adjusted)
Italian Diabetic Multivessel (adjusted)
Study ID
McMaster STEMI (adjusted)
GHOST (adjusted)
REAL (adjusted)
Brazil Large Vessels
Melbourne
ACUITY (from RCT)
Cedars Acute MI
I-V Overall
NHLBI (on label, adjusted)
Mayo FFR Substudy
Harbor AMI
Wake Forest (adjusted)
STENT (adjusted)
ARTS II (from RCT)
ERACI III (from RCT)
SCAAR (adjusted)
Asan Korea (adjusted)
DEScover (unadjusted)
Washington Hosp Center (matched)
Germany Metabolic Syndrome
Massachusetts (matched)
NHLBI (off label, adjusted)
0.87 (0.78, 0.97)
0.80 (0.52, 1.23)
1.10 (0.91, 1.32)
1.29 (1.06, 1.57)
1.02 (0.46, 2.25)
ES (95% CI)
0.28 (0.04, 1.71)
1.12 (0.74, 1.70)
0.92 (0.76, 1.11)
1.50 (0.25, 8.90)
1.00 (0.39, 2.58)
1.07 (0.91, 1.25)
0.25 (0.06, 1.16)
0.95 (0.91, 1.00)
0.71 (0.47, 1.05)
0.67 (0.12, 3.84)
0.19 (0.05, 0.69)
0.84 (0.60, 1.18)
0.69 (0.52, 0.92)
0.53 (0.32, 0.88)
2.30 (0.91, 5.96)
1.01 (0.91, 1.11)
0.66 (0.42, 1.05)
0.69 (0.40, 1.18)
0.51 (0.29, 0.88)
0.23 (0.07, 0.78)
0.92 (0.83, 1.02)
0.71 (0.50, 1.00)
100.00
3.96
8.04
Weight
7.83
1.59
(D+L)
0.32
4.14
7.97
0.36
1.17
8.59
0.51
4.31
0.38
0.64
5.21
6.09
3.20
1.18
9.67
3.66
2.91
2.81
0.75
9.61
5.08
%
0.87 (0.78, 0.97)
0.80 (0.52, 1.23)
1.10 (0.91, 1.32)
1.29 (1.06, 1.57)
1.02 (0.46, 2.25)
ES (95% CI)
0.28 (0.04, 1.71)
1.12 (0.74, 1.70)
0.92 (0.76, 1.11)
1.50 (0.25, 8.90)
1.00 (0.39, 2.58)
1.07 (0.91, 1.25)
0.25 (0.06, 1.16)
0.95 (0.91, 1.00)
0.71 (0.47, 1.05)
0.67 (0.12, 3.84)
0.19 (0.05, 0.69)
0.84 (0.60, 1.18)
0.69 (0.52, 0.92)
0.53 (0.32, 0.88)
2.30 (0.91, 5.96)
1.01 (0.91, 1.11)
0.66 (0.42, 1.05)
0.69 (0.40, 1.18)
0.51 (0.29, 0.88)
0.23 (0.07, 0.78)
0.92 (0.83, 1.02)
0.71 (0.50, 1.00)
100.00
3.96
8.04
Weight
7.83
1.59
(D+L)
0.32
4.14
7.97
0.36
1.17
8.59
0.51
4.31
0.38
0.64
5.21
6.09
3.20
1.18
9.67
3.66
2.91
2.81
0.75
9.61
5.08
%
1.1 1 10
MI: All RegistriesMI: All Registries130,191 patients, 25 registries , mean F/U 2.5 years130,191 patients, 25 registries , mean F/U 2.5 years
Favors DES Favors BMS
Estimate (95% CI) Weight (%)
0.87 (0.78,0.97), p=0.01 0.95 (0.91,1.00)
*Random Effects (I2=60%)Fixed Effects
*MI is QWMI in Washington Hospital Center, RESTEMKirtane et al, Circ 2009;119: 3198-3206
NOTE: Weights are from random effects analysis
D+L Overall (I-squared = 69.7%, p = 0.000)
REAL (adjusted)
Multicenter SVG (adjusted)
STENT (adjusted)
ERACI III (from RCT)
GHOST (adjusted)
Study ID
I-V Overall
Asan Korea (adjusted)
Washington Hosp Center (matched)
Sussex Elderly
Montevergine
DEScover (adjusted)
NY State (adjusted, unmatched)
McMaster STEMI (adjusted)
Wake Forest (adjusted)
Ontario (matched)
Brazil Large Vessels
Cedars Acute MI
RESTEM
Mayo FFR Substudy
0.54 (0.47, 0.61)
0.67 (0.59, 0.76)
0.58 (0.28, 1.18)
0.58 (0.47, 0.71)
0.58 (0.39, 0.86)
0.28 (0.20, 0.39)
ES (95% CI)
0.57 (0.54, 0.60)
0.32 (0.24, 0.43)
0.65 (0.49, 0.85)
0.84 (0.28, 2.54)
0.51 (0.39, 0.68)
0.58 (0.40, 0.83)
0.54 (0.50, 0.60)
0.32 (0.05, 1.92)
0.63 (0.48, 0.83)
0.69 (0.60, 0.80)
0.43 (0.17, 1.10)
0.22 (0.08, 0.62)
0.62 (0.47, 0.80)
0.18 (0.04, 0.78)
100.00
10.09
2.37
8.61
5.27
6.22
(D+L)
6.97
Weight
7.26
1.15
7.22
5.73
10.63
0.45
7.29
9.80
1.54
1.31
7.44
0.66
%
0.54 (0.47, 0.61)
0.67 (0.59, 0.76)
0.58 (0.28, 1.18)
0.58 (0.47, 0.71)
0.58 (0.39, 0.86)
0.28 (0.20, 0.39)
ES (95% CI)
0.57 (0.54, 0.60)
0.32 (0.24, 0.43)
0.65 (0.49, 0.85)
0.84 (0.28, 2.54)
0.51 (0.39, 0.68)
0.58 (0.40, 0.83)
0.54 (0.50, 0.60)
0.32 (0.05, 1.92)
0.63 (0.48, 0.83)
0.69 (0.60, 0.80)
0.43 (0.17, 1.10)
0.22 (0.08, 0.62)
0.62 (0.47, 0.80)
0.18 (0.04, 0.78)
100.00
10.09
2.37
8.61
5.27
6.22
(D+L)
6.97
Weight
7.26
1.15
7.22
5.73
10.63
0.45
7.29
9.80
1.54
1.31
7.44
0.66
%
1.1 1 10
TVR: All RegistriesTVR: All Registries74,154 pts, 18 registries , mean F/U 2.2 years74,154 pts, 18 registries , mean F/U 2.2 years
Favors DES Favors BMS
Estimate (95% CI) Weight (%)
0.54 (0.48,0.61), p<0.001 0.57 (0.54,0.60)
*Random Effects (I2=70%)Fixed Effects
Kirtane et al, Circ 2009;119: 3198-3206
Summary: DES vs. BMSSummary: DES vs. BMS Treatment Effect EstimatesTreatment Effect Estimates
MortalityMortality MIMI TVRTVR
RCTsRCTs 8,867 pts, 8,867 pts, 21 trials 21 trials
8,850 pts, 8,850 pts, 20 trials 20 trials
7,291 pts, 7,291 pts, 16 trials 16 trials
- Fixed effectsFixed effects- Random effectsRandom effects
0.970.970.970.97
0.950.950.940.94
0.510.510.450.45
RegistriesRegistries 169,595 pts, 169,595 pts, 31 studies 31 studies
130,191 pts, 130,191 pts, 25 studies 25 studies
74,154 pts, 74,154 pts, 18 studies 18 studies
- Fixed effectsFixed effects- Random effectsRandom effects
0.810.810.780.78
0.950.950.870.87
0.570.570.540.54
<1.0 <1.0 DES better DES better
Kirtane et al, Circ 2009;119: 3198-3206
First AuthorFirst Author JournalJournal DES ptsDES pts BMS ptsBMS pts F/U F/U YearsYears
DES DES MortalityMortality
BMS BMS MortalityMortality pp
GroeneveldGroeneveld JACCJACC 71,96571,965 71,96571,965 22 10.7%10.7% 13.5%13.5% <0.001<0.001
Shishebor Shishebor JACCJACC 6,0536,053 1,9831,983 4.54.5 8.0%8.0% 17.0%17.0% <0.001<0.001
WangWang CCICCI 3,4173,417 4,1494,149 11 6.0%6.0% 11.4%11.4% <0.0001<0.0001
AnstromAnstrom Arch Int MedArch Int Med 1,5011,501 3,1653,165 22 8.6%8.6% 8.6%8.6% 0.940.94
AustinAustin Circ InterventionsCirc Interventions 1,1051,105 6,3946,394 22 6.6%6.6% 7.7%7.7% 0.040.04
Vlaar Vlaar CCICCI 536536 557557 22 6.4%6.4% 6.4%6.4% 0.930.93
YanYan IJCIJC 239239 433433 11 0.5%0.5% 2.9%2.9% 0.070.07
AlidoostiAlidoosti Hellen J CardHellen J Card 228228 15681568 1.51.5 5.3%5.3% 4.7%4.7% 0.100.10
Dominguez FrancoDominguez Franco Clin CardiologyClin Cardiology 205205 215215 1.51.5 6.3%6.3% 8.4%8.4% NSNS
RamanaRamana CCICCI 141141 170170 33 6.0%6.0% 12.0%12.0% 0.050.05
NuscaNusca AJCAJC 121121 113113 33 12.0%12.0% 21.0%21.0% <0.05<0.05
GarroGarro EurointerventionEurointervention 117117 128128 22 4.4%4.4% 4.1%4.1% 1.01.0
OkadaOkada Circ JCirc J 8080 124124 11 16.3%16.3% 19.8%19.8% 0.490.49
AssaliAssali EurointerventionEurointervention 6868 4343 22 2.9%2.9% 4.7%4.7% 0.600.60
Malenka et al (JAMA) excluded for DES era/BMS era comparison; 4 additional studies reported cardiac death onlyMalenka et al (JAMA) excluded for DES era/BMS era comparison; 4 additional studies reported cardiac death only
14 Subsequent DES vs. BMS Registries14 Subsequent DES vs. BMS RegistriesPublished 2/08-9/08 (N=176,777 pts)*Published 2/08-9/08 (N=176,777 pts)*
*Studies already included in meta-analysis*Studies already included in meta-analysisin unpublished format not listedin unpublished format not listed
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