Comparison of Biolimus Eluted From an Erodable Stent Coating With Bare-Metal Stents in Acute ST-Elevation Myocardial Infarction and In Vivo 3-Vessel Assessment of Time-Related Changes of Culprit and Non-Culprit Lesions by IVUS/OCT in AMI
试验速览
- 阶段
- 4 期
- 状态
- 已完成
- 入组人数
- 1,161
- 试验地点
- 7
- 主要终点
- Major adverse cardiac events (MACEs) in the overall population, defined as the composite of cardiac death, target-vessel related myocardial infarction (Q-wave and non-Q-wave), or ischemia-driven target lesion revascularization within 12 months
研究概览
简要总结
Stent study:
Treatment of patients with acute myocardial infarction with drug eluting stents (DES) is effective but there remain concerns regarding the long-term safety and adverse effects on the adjacent arterial wall. The biolimus-eluting Biomatrix stent addresses the issues by incorporating modifications as a biodegradable polymer and a drug application solely to the abluminal stent surface. While clinical data about the biolimus-eluting stent show a favorable safety and efficacy profile, they require confirmation in a dedicated randomised trial in the subset of patients with STEMI. Therefore, the study is designed to compare the safety and efficacy of biolimus-eluting Biomatrix stent as compared to a bare metal stent of otherwise identical design in a prospective, multicenter, randomized, controlled superiority trial in patients with acute ST-elevation myocardial infarction.
Stent and Plaque Imaging Substudy:
In a substudy of the above mentioned stent trial, the investigators will perform a prospective, multicenter, longitudinal cohort study of 100 consecutive STEMI patients undergoing urgent coronary angiography and will employ high-resolution Optical Coherence Tomography (OCT) imaging technology and intra-vascular ultrasound and virtual histology (IVUS-VH) of the culprit STEMI lesions pre- and postprocedural as well as at a 13 months follow up. Assessment of vascular wall responses, including volumetric measurements of vessel, stent, lumen, peri-stent plaque, and intimal hyperplasia, indices of remodeling, stent expansion, and stent-vessel wall apposition in response to biolimus-eluting and bare-metal stent implantation will be performed. Moreover, IVUS, IVUS-VH and OCT will be performed in all three epicardial vessels in order to quantify and map the number, frequency and distribution of ruptured plaques at baseline and follow-up and quantify the morphological changes of ruptured and vulnerable plaques at baseline and follow-up and quantify the morphological changes over time in response to standard medical treatment. Therefore, new insight regarding the frequency, distribution, composition and evolution of coronary artery plaques and their prognostic impact on patients clinical outcome can be expected from the present study. Since patients suffer from a recurrent ischemic event rate of 5-10% during the first year, these findings may have important therapeutic implications for the medical treatment of affected patients to further reduce the risk of recurrence and improve prognosis.
详细描述
Background
Stent Study:
A routine invasive strategy using percutaneous coronary intervention (PCI) has been shown to improve survival and freedom from recurrent myocardial infarction compared to a thrombolysis in patients with acute ST-elevation myocardial infarction (STEMI). In addition to standard medical treatment, PCI with the use of coronary artery stents not only eliminate the underlying stenotic lesion, but afford a mechanical mean of plaque stabilization, normalize coronary blood flow, reduce shear stress, and local intracoronary thrombosis. Notwithstanding, the implantation of coronary artery stents is associated with arterial injury initiating a vasculo-proliferative cascade and as a result provoke structural changes of the vessel wall. The implantation of bare-metal stents (BMS) during primary percutaneous coronary interventions (P-PCI) in STEMI patients resulted in restenosis in up to 20% of patients and has not been shown to reduce the rate of mortality and reinfarction. Randomised trials and meta-analyses showed that the use of drug-eluting stents (DES) compared with BMS in patients with STEMI significantly reduces the rate of target lesion revascularization (TLR) without negative impact on the rate of death and myocardial infarction up to one year.
However, there remain important caveats surrounding the safety of DES in patients with STEMI and evidence of harm may only arise during longer term follow up. DES implantation into culprit lesions of patients with acute coronary syndromes has been identified as independent predictor of late stent thrombosis. DES as opposed to BMS implanted into a pro-thrombotic, inflammatory milieu of ruptured plaques in STEMI patients may lead to aneurysmal changes of the adjacent vessel wall. First generation DES implanted into STEMI lesions were found to be associated with substantial delay in healing compared to BMS. Moreover, DES implanted into STEMI lesions have been associated with a higher frequency of incompletely apposed struts and uncovered struts as assessed by OCT compared with DES implanted into stable lesions. These data suggest a significantly increased risk of late thrombotic complications related to DES. The phenomenon of aneurysmal change of the vessel wall may lead to incomplete stent apposition, which in turn may predispose to late complications such as stent thrombosis, recurrent myocardial infarction, and death. In conclusion, although coronary artery stents constitute a routine medical intervention to improve the acute and long-term result in STEMI patients, only very limited information exists as to the long-term clinical outcome and structural changes of the adjacent vessel wall.
First generation DES with controlled release of sirolimus or paclitaxel from durable polymers have reduced angiographic and clinical measures of restenosis in patients with STEMI. Limus analogues are more effective as site-specific agents than paclitaxel to reduce neointimal growth and repeat revascularisation procedures. However, late stent thrombosis is more germane to first-generation drug-eluting stents than to bare-metal stents owing to delayed healing and re-endothelialization. Furthermore, hypersensitivity reactions from the polymers may further increase the risk of stent thrombosis. These effects may be particularly pronounced in ruptured plaques of STEMI patients due to the direct contact with the necrotic core.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Treatment
- 盲法
- Single (Outcomes Assessor)
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Age equal or more than 18 years
- •Chest pain > 10 minutes
- •Primary pci
- •ST-segment elevation of > 1 mm in > 2 contiguous leads, or (presumably new) left bundle branch block, or true posterior MI with ST depression of > 1 mm in > 2 contiguous anterior leads
- •Presence of at least one acute infarct artery target vessel with one or more coronary artery stenoses in a native coronary artery from 2.25-4 mm in diameter that can be covered with 1-multiple stents
排除标准
- •Female of childbearing potential (age 50 and last menstruation within the last 12 months), who did not underwent tubal ligation, ovariectomy or hysterectomy
- •Known intolerance to aspirin, clopidogrel, heparin, stainless steel, biolimus or contrast material
- •Inability to provide informed consent
- •Currently participating in another trial before reaching first endpoint
- •Mechanical complication of acute myocardial infarction
- •Acute myocardial infarction secondary to stent thrombosis
- •Planned surgery within 6 months of PCI unless dual antiplatelet therapy is maintained throughout the perisurgical period
- •Noncardiac comorbid conditions are present with life expectancy 1 year or that may result in protocol malcompliance
- •History of bleeding diathesis or known coagulopathy
- •Use of Coumadin
- •Additional for Imaging Substudy:
- •Age > 90 years
- •Hemodynamic instability
- •Renal failure
- •OCT/IVUS technically not feasible
- •Any patient in whom angiography demonstrates the infarct lesion to be at the site of a previously implanted stent
结局指标
主要结局
Major adverse cardiac events (MACEs) in the overall population, defined as the composite of cardiac death, target-vessel related myocardial infarction (Q-wave and non-Q-wave), or ischemia-driven target lesion revascularization within 12 months
时间窗: 30 days, 6 months, 1,2 and 5 years
次要结局
- All deaths(30 days, 6 months, 1,2 and 5 years)
- Clinically and non-clinically indicated target lesion revascularizations(30 days, 6 months, 1, 2 and 5 years)
- Stent thrombosis ARC defined(30 days, 1,2 and 5 years)
- Stent strut coverage as assessed by OCT(13 months)
- Malapposition as assessed by OCT/IVUS(13 months)