Elsevier

American Heart Journal

Volume 151, Issue 6, June 2006, Pages 1260-1264
American Heart Journal

Clinical Investigation
Interventional Cardiology
Bare metal stent restenosis is not a benign clinical entity

https://doi.org/10.1016/j.ahj.2005.08.011Get rights and content

Background

Restenosis after percutaneous coronary intervention (PCI) has been thought to present in a stable manner as exertional angina. However, the presentation of in-stent restenosis (ISR) is not well-studied. We hypothesized that a substantial proportion of bare metal ISR presents as acute coronary syndromes. We aimed to characterize the severity of the clinical presentation of ISR.

Methods

We searched our PCI database for all cases of PCI for bare metal ISR occurring between May 1999 and September 2003. Multivessel interventions were excluded. In-stent restenosis presentation was classified into three categories: (1) myocardial infarction (MI), (2) unstable angina requiring hospitalization before angiography, and (3) exertional angina. Routine angiographic screening after initial stent placement was not performed, so ISR episodes were clinical, rather than angiographic, ISR.

Results

We identified 1186 cases of bare metal ISR in 984 patients. Median age was 63, 72% were male, and 36% had diabetes. Of the ISR episodes, 9.5% presented as acute MI (7.3% as non–ST-segment elevation MI and 2.2% as ST-segment elevation MI), 26.4% as unstable angina requiring hospitalization before angiography, and 64.1% as exertional angina.

Conclusions

More than one third of bare metal ISR episodes presented as MI or unstable angina requiring hospitalization. The acuity of the clinical presentation of bare metal ISR appears to be more severe than has been previously thought. Aggressive efforts, such as drug-eluting stents to decrease the incidence of unstable angina due to bare metal ISR, are warranted.

Section snippets

Study sample

From May 1999 to September 2003, a total of 10 472 PCIs were performed at the Cleveland Clinic. Our PCI database was queried for all PCIs performed for bare metal ISR during this period. In this study, ISR was considered to be any stent restenosis severe enough to warrant repeat PCI. In-stent restenosis was not confined to restenosis in the stent, but instead included edge restenosis. Target vessel repeat revascularization (outside the stent and its edges) was not considered as ISR. There was

Baseline characteristics

Median age of the 984 subjects was 63 years (interquartile range, 54-72 years). A total of 72% were male, 36% had diabetes, 51% had prior MI, and 39% had prior coronary artery bypass surgery (Table I).

Clinical characteristics of bare metal ISR presentation

Of the 1186 cases of bare metal ISR in 984 patients, a total of 64.1% presented as exertional angina, 26.4% as unstable angina requiring hospitalization before coronary angiography, and 9.5% as acute MI (7.3% as non–ST-segment elevation MI and 2.2% as ST-segment elevation MI) (Table II and Figure 1

Primary finding and comparison with prior studies

We characterize the clinical presentation of bare metal ISR in the largest series to date. Our primary finding was that bare metal ISR, contrary to general perception,6 is not a benign clinical entity. In 1186 consecutive cases of clinical episodes of bare metal ISR, a total of 9.5% presented as MI and 26.7% as unstable angina requiring hospitalization. We also demonstrate that the MIs associated with ISR are not just small enzyme abnormalities but can in fact be substantial, for 18% of MI

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This work was not funded by any grants.

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