Improved drug-eluting stents for left main PCI in an all-comers population: 5-Year results of the IDEAL-LM trial

Published in Congress: EuroPCR 2024

Dr. Özkan Bekler

Introduction: The use of percutaneous coronary intervention (PCI) for left main coronary artery (LM) disease is increasing worldwide. However, the optimal duration of dual antiplatelet therapy (DAPT) following LM PCI remains undetermined. Biodegradable polymer-coated thin-strut drug-eluting stents (DES) may facilitate faster healing and allow for a shorter DAPT duration, thereby reducing target lesion revascularization (TLR).

Objective: The IDEAL-LM study aimed to compare the 5-year major adverse cardiac events (MACE) between two different DES, Synergy and Xience, in patients undergoing LMCA PCI and to evaluate the safety and efficacy of a shortened DAPT regimen.

Methods: This multicenter, international randomized controlled trial included patients indicated for LM revascularization according to ESC guidelines. Participants were randomized to receive either the Synergy stent (with a 4-month DAPT regimen) or the Xience stent (with a 12-month DAPT regimen). The primary endpoint was the 2-year MACE, defined as death, myocardial infarction (MI), and ischemia-driven target vessel revascularization (TVR). The final endpoint was the 5-year MACE.

Results: Between December 2014 and September 2016, a total of 818 patients were enrolled from 29 centers across 5 countries. The primary outcome measure of 2-year MACE was 14.6% in the Synergy group and 11.4% in the Xience group, confirming non-inferiority. Similar results were observed at the 5-year follow-up, with MACE rates of 22.5% for Synergy and 24.1% for Xience. The use of Synergy stents with a 4-month DAPT regimen yielded excellent long-term results comparable to those of previous studies involving coronary artery bypass grafting.

Conclusions: The use of Synergy stents with a 4-month DAPT regimen was found to be safe and effective for patients undergoing LM PCI, providing long-term outcomes similar to those with Xience stents and a 12-month DAPT regimen. This suggests that a shorter DAPT duration may be a suitable option for certain patients.

Commentary: The results of the IDEAL-LM study demonstrate that the use of new drug-eluting stents (DES) with a shortened DAPT regimen is safe in patients undergoing LM PCI and that long-term outcomes are comparable to those with a longer DAPT regimen. This finding supports the strategy of administering a shorter DAPT duration for patients at high risk of bleeding. Further long-term studies are needed to confirm these results and to determine the optimal DAPT duration for various patient populations.