Vol 28, No 2 (2021)
Original Article
Published online: 2019-11-06

open access

Page views 1544
Article views/downloads 1340
Get Citation

Connect on Social Media

Connect on Social Media

Efficacy and safety of drug-eluting stents in elderly patients: A meta-analysis of randomized trials

SungA Bae1, Yongcheol Kim1, Bill D. Gogas2, Min Chul Kim1, Doo Sun Sim1, Young Joon Hong1, Ju Han Kim1, Youngkeun Ahn1, Myung Ho Jeong1
Pubmed: 31702046
Cardiol J 2021;28(2):223-234.


Background: Current guidelines recommend newer generation drug-eluting stents (DES) over bare-metal stents (BMS) in patients with ischemic heart disease. However, there is no age-specific recommendation in elderly patients.

Methods: Meta-analysis was performed of 6 randomized studies enrolling 5,042 elderly patients who underwent percutaneous coronary intervention (PCI) with stent implantation (DES, n = 2,579; BMS, n = 2,463).

Results: Combined data indicated a significant reduction in major adverse cardiovascular events (MACEs) with use of DES (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.44–0.71, p < 0.001). Moreover, use of DES was associated with a significantly lower incidence of myocardial infarction (OR 0.54, 95% CI 0.36–0.81, p = 0.003) and repeat revascularization (OR 0.44, 95% CI 0.31–0.62, p < 0.001), was compared to that with the use of BMS. Stent thrombosis and bleeding complication rates were not significantly different between groups. In a subgroup meta-analysis, short duration (1 or 6 months) dual antiplatelet therapy (DAPT) was associated with a significantly lower MACE rate (OR 0.49, 95% CI 0.34–0.80; p = 0.003) in elderly patients who underwent PCI with everolimuseluting stent implantation, compared with that using long duration DAPT.

Conclusions: This meta-analysis provides clinically relevant evidence that DES rather than BMS should be selected for elderly patients.

Article available in PDF format

View PDF Download PDF file


  1. Menichelli M, Parma A, Pucci E, et al. Randomized trial of Sirolimus-Eluting Stent Versus Bare-Metal Stent in Acute Myocardial Infarction (SESAMI). J Am Coll Cardiol. 2007; 49(19): 1924–1930.
  2. Spaulding C, Henry P, Teiger E, et al. TYPHOON Investigators. Sirolimus-eluting versus uncoated stents in acute myocardial infarction. N Engl J Med. 2006; 355(11): 1093–1104.
  3. Laarman GJ, Suttorp MJ, Dirksen MT, et al. Paclitaxel-eluting versus uncoated stents in primary percutaneous coronary intervention. N Engl J Med. 2006; 355(11): 1105–1113.
  4. Stettler C, Wandel S, Allemann S, et al. Outcomes associated with drug-eluting and bare-metal stents: a collaborative network meta-analysis. Lancet. 2007; 370(9591): 937–948.
  5. Horst B, Rihal CS, Holmes DR, et al. Comparison of drug-eluting and bare-metal stents for stable coronary artery disease. JACC Cardiovasc Interv. 2009; 2(4): 321–328.
  6. Cassese S, Byrne RA, Tada T, et al. Clinical impact of extended dual antiplatelet therapy after percutaneous coronary interventions in the drug-eluting stent era: a meta-analysis of randomized trials. Eur Heart J. 2012; 33(24): 3078–3087.
  7. Gerber RT, Arri SS, Mohamed MO, et al. Age is not a bar to PCI: Insights from the long-term outcomes from off-site PCI in a real-world setting. J Interv Cardiol. 2017; 30(4): 347–355.
  8. Rich MW, Chyun DA, Skolnick AH, et al. Knowledge Gaps in Cardiovascular Care of the Older Adult Population: A Scientific Statement From the American Heart Association, American College of Cardiology, and American Geriatrics Society. J Am Coll Cardiol. 2016; 67(20): 2419–2440.
  9. Varenne O, Cook S, Sideris G, et al. Drug-eluting stents in elderly patients with coronary artery disease (SENIOR): a randomised single-blind trial. Lancet. 2018; 391(10115): 41–50.
  10. de Belder A, de la Torre Hernandez JM, Lopez-Palop R, et al. A prospective randomized trial of everolimus-eluting stents versus bare-metal stents in octogenarians: the XIMA Trial (Xience or Vision Stents for the Management of Angina in the Elderly). J Am Coll Cardiol. 2014; 63(14): 1371–1375.
  11. Leidi F, Schiavon R. Drug-eluting stents vs. bare metal stents in elderly patients. Intern Emerg Med. 2018; 13(5): 773–774.
  12. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009; 339: b2535–b2535.
  13. Cutlip DE, Windecker S, Mehran R, et al. Academic Research Consortium. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation. 2007; 115(17): 2344–2351.
  14. Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation. 2011; 123(23): 2736–2747.
  15. Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011; 343: d5928.
  16. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ. 2004; 328(7454): 1490.
  17. Higgins JPT, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ. 2003; 327(7414): 557–560.
  18. Egger M, Davey Smith G, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997; 315(7109): 629–634.
  19. Morice MC, Talwar S, Gaemperli O, et al. Drug-coated versus bare-metal stents for elderly patients: A predefined sub-study of the LEADERS FREE trial. Int J Cardiol. 2017; 243: 110–115.
  20. Ariotti S, Adamo M, Costa F, et al. Is Bare-Metal Stent Implantation Still Justifiable in High Bleeding Risk Patients Undergoing Percutaneous Coronary Intervention?: A Pre-Specified Analysis From the ZEUS Trial. JACC Cardiovasc Interv. 2016; 9(5): 426–436.
  21. Kurz DJ, Bernheim AM, Tüller D, et al. Improved outcomes of elderly patients treated with drug-eluting versus bare metal stents in large coronary arteries: results from the BAsel Stent Kosten-Effektivitäts Trial PROspective Validation Examination randomized trial. Am Heart J. 2015; 170(4): 787–795.e1.
  22. Ielasi A, Brugaletta S, Silvestro A, et al. Everolimus-eluting stent versus bare-metal stent in elderly (≥75 years) versus non-elderly (<75 years) patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: insights from the examination trial. Int J Cardiol. 2015; 179: 73–78.
  23. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39(2): 119–177.
  24. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. Considerations for the choice between coronary artery bypass grafting and percutaneous coronary intervention as revascularization strategies in major categories of patients with stable multivessel coronary artery disease: an accompanying article of the task force of the 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2019; 40(2): 204–212.
  25. Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2018; 39(3): 213–260.
  26. Bønaa KH, Mannsverk J, Wiseth R, et al. Drug-eluting or bare-metal stents for coronary artery disease. N Engl J Med. 2016; 375(13): 1242–1252.
  27. Yeh RW, Secemsky EA, Kereiakes DJ, et al. Development and Validation of a Prediction Rule for Benefit and Harm of Dual Antiplatelet Therapy Beyond 1 Year After Percutaneous Coronary Intervention. JAMA. 2016; 315(16): 1735–1749.
  28. Costa F, van Klaveren D, James S, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet. 2017; 389(10073): 1025–1034.
  29. Ndrepepa G, Neumann FJ, Schulz S, et al. Incidence and prognostic value of bleeding after percutaneous coronary intervention in patients older than 75 years of age. Catheter Cardiovasc Interv. 2014; 83(2): 182–189.
  30. Mori H, Cheng Qi, Lutter C, et al. Endothelial barrier protein expression in Biodegradable polymer sirolimus-eluting versus durable polymer everolimus-eluting metallic stents. JACC Cardiovasc Interv. 2017; 10(23): 2375–2387.