1. Tarunjit Singh Department of Internal Medicine Westchester Medical Center New York Medical College Valhalla NY

2.  To compare Major Adverse Cardiac Events (MACE) in Bare- metal versus drug-eluting stent in patients treated with TNK prior to being admitted to our facility for PCI.

3. Defined as occurrence of one of the following :  Myocardial Infarction  Target Vessel Revascularization  Death

4. Prehospital Fibrinolysis  Improvement in survival  Smaller infarct size  Improved ventricular healing  Reduction in the extent of left ventricular dysfunction  Greater electrical stability

5.  GISSI-2 and ISIS-2 – Streptokinase  GUSTO-I trial – Alteplase  GUSTO III trial compared Reteplase with Alteplase  ASSENT-2 compared Tenecteplase to Alteplase  The net effect in major thrombolytic trials has been an approximately 30 percent reduction in short-term mortality to a value of 7 to 10 percent.

7. PCI after fibrinolysis  There are three settings in which Percutaneous Coronary Intervention (PCI) is performed after fibrinolysis:  Facilitated PCI, in which a fibrinolytic drug is given prior to planned PCI in an attempt to achieve an open infarct-related artery before arrival in the catheterization laboratory  Rescue / Salvage PCI is defined as PCI performed within 12 hours of failed fibrinolysis (primary failure) in patients with evidence of continuing or recurrent myocardial ischemia

8.  Analysis of 376 consecutive patients,out of which 102 received BMS and 274 received DES from 2003 to 2005.  The 376 patients were followed for a period of 43± 17 months.  End point of follow-up was occurrence of MACE.  Choice of stent type was at the discretion of the operator.  Chi-square or Fisher’s exact test were done for categorical variables.  Student’s T test were done for continuous variables.

9. VariableBMS (n= 102) DES (n= 274) P value Age (years)64 ± 1263 ± 12ns Male73 (72%)197 (72%)ns Female29 (28%)77 (28%)ns Smoking48 (45%)98 (36%)ns Hypertension94 (92%)263 (96%)ns Dyslipidemia99 (97%)266 (97%)ns Diabetes mellitus39 (38%)118 (43%)ns BMI ≥ 30 kg/m²34 (33%)65 (24%)ns

10. VariableBMSDESP value Aspirin use101 (99%)271 (99%)ns Clopidogrel use102 (100%)274 (100%)ns Beta blockers use90 (88%)260 (95%)ns Ace Inhibitor use45 (44%)129 (47%)ns Statin use99 (97%)271 (99%)ns Follow-up (months) 42 ± 1943 ± 15ns Coronary artery bypass grafting 13 (13%)18 (7%)ns

11. No of vessel diseased BMSDESP value 1-vessel disease53 (52%)134(49%)Ns 2 vessel disease22 (22%)89 (32%)Ns 3 vessel disease27 (26%)51 (19%)Ns

12. Lesion ComplexityP value Type A34 (33%)106 (39%)ns Type B29 (29%)95 (34%)ns Type C39 (38%)73 (27%)ns Stent length (mm)27 ± 1525 ± 14ns Stent width (mm)3.2 ± 0.63.0 ± 0.3<.0001

13. VariableBMS (n=102) DES (n=204) P value Myocardial infarction 4 (4%)8 (3%)ns TVR16 (16%)27 (10%)ns Death12 (12%)14 (5%)0.024 MACE25 (25%)40 (15%)0.024

14. Prognostic Factors Parameter Estimate Standard Error P valueHazard Ratio Prior coronary artery surgery 0.7970.3390.0192.218 Width of stent -0.8160.2960.0060.442 Bare-metal stent 0.6040.2590.0191.830

15.  Prior CABG surgery, Decreased stent width and the use of bare-metal stents (BMS) were independent risk factors for MACE.  BMS had a 1.8 times higher incidence of developing MACE as compared to DES.  No increased rate of acute or chronic thrombosis after thrombolysis in either group. The increased rate of MACE in BMS group may be attributed to increased incidence of restenosis.

16.  THANK YOU