Interventional cardiologist are excessively talented guys .They always lead ahead in innovations .The only issue is , their enthusiasm ( many times overtake the pace of science . In the name of off label indications they indulge in drug and device extravaganza in uncharted territory .
Even as we boast of practicing evidence based cardiology scientific adventures happen without proper evidence . . . rather we have wait for evidence to come later .” A clear case of cart pulling the horse “
The wide-spread of use of second generation DES in STEMI has not been found to superior to BMS in the EXAMINATION trial just released in ESC 2011 Paris. It failed miserably , when every one took the superiority for granted.( Some may claim non inferiority is not a failure , but for a DES which was perceived a revolution, it is definitely a failure in the STEMI subset )
Further, what EXAMINATION trial did not address is acute and sub acute stent thrombosis .Even as the DES is credited with a dubious record for sub acute stent thrombosis , there is every reason to suspect , in the milieu of STEMI the thrombotic risk of DES would increase many fold.
The seemingly low incidence of stent thrombosis with DES in STEMI , in EXAMINATION trail is a statistical mirage .This trial was neither planned nor powered to address the issue of stent thrombosis.
In the ultimate analysis of EXAMINATION , One could conclude Cobalt chromium BMS, has cemented its place , more firmly for use in primary PCI.
DES at best ( *With all those conditions apply , Dual antiplatelet etc) can be equal to BMS, while BMS at any day , would casually will win over DES without any conditions at a huge cost advantage.
The above analysis is diagonally opposite to that of general perception that emanated from Paris ESC meet 2011 trial .
Please remember EXAMINATION trial did not reach its desired primary end point !
That is a strong point against it .What do you think ?
Reference
http://www.theheart.org/article/1272077.do
A TV debate on Examination trial from EURO PCR
http://www.oxfordjournals.org/our_journals/eurheartj/ehjvideo.html
Dr.S.Venkatesan MD 