Letter to the Editor Oral Sirolimus After Bare Metal Stent Implantation: A Glimpse to the Future TO THE EDITOR Drug eluting stents (DES) significantly reduced the incidence of angiographic restenosis and target lesion revascularization after percutaneous coronary interven- tions (PCI), although presence of late and very late stent thrombosis, delayed healing, endothelial dysfunc- tion, and late stent acquired mal-apposition are more frequently linked with DES implantation [1]. In the February issue of the Journal, Stojkovic et al. [2] are presenting new randomized data with oral sirolimus af- ter bare metal stent (BMS) implantation. In this oppor- tunity, for the first time the authors are not using an initial bolus dose of rapamycin. This trial [2] added a new important piece of information: 1. Independently to the dose and treatment length, all randomized studies with oral Sirolimus after BMS [3], some of them quoted by authors in the manu- script, have been shown a significant reduction of angiographic restenosis and target lesion and target vessel revascularization. Furthermore, recent randomized head to head comparison with DES, demonstrated similar safety and efficacy but with significant lower cost with the oral sirolimus ther- apy, benefits which were maintained at long term follow-up [4]. 2. Amount of late loss reported by the authors [2] are lower than other studies [5,6] described with short period of the oral therapy, suggested that 30 days of treatment could be responsible with this angio- graphic benefit. 3. Side effects around 25% were always present; although they are minor, few patients discontinue the drug and disappeared completely after withdraw the treatment. Finally, taking in account that around 15–20% of PCI candidates are non responsive or unable to take long-term dual antiplatelet therapy [7]; in all of these cases, alternative therapies to DES should be found. Interventional cardiology cannot be seen as ‘‘black or white’’; our patients deserve the best tailored treat- ment either DES, BMS alone, or associated with thera- pies as authors are reporting in the Journal. Juan Mieres, MD Carlos Fernandez-Pereira, MD, FACC, FSCAI Alfredo E. Rodriguez, MD, PHD, FACC FSCAI for ORAR Investigators Cardiovascular Research Center (CECI) Otamendi Hospital, Buenos Aires, Argentina REFERENCES 1. Camenzind E, Steg PG, Wijns W. Stent thrombosis late after implantation of first-generation drug-eluting stents: A cause for concern. Circulation 2007;115:1440–1455. 2. Stojkovic S, Ostojic M, Nedeljkovic M, Stankovic G, Beleslin B, Vukcevic V, Orlic D, Arandjelovic A, Kostic J, Dikic M, Tomasevic M. Systemic rapamycin without loading dose for re- stenosis prevention after coronary bare metal stent implantation. Catheter Cardiovasc Interv 2010;75:317–325. 3. Rodriguez AE. Emerging drugs for coronary restenosis: The role of systemic oral agents in stent era. Expert Opin Emerg Drugs 2009;14:1–16. 4. Rodriguez AE, Maree A, Tarragona S, Fernandez-Pereira C, Santaera O, Granillo AM, Rodriguez-Granillo GA, Russo-Fels- sen M, Kukreja N, Antoniucci D, Palacios IF, Serruys PW; ORAR III Investigators. Percutaneous coronary intervention with oral sirolimus and bare metal stents has comparable safety and efficacy to treatment with drug eluting stents, but with significant cost saving: Long-term follow-up results from the randomised, controlled ORAR III (oral rapamycin in Argentina) study. Euro- Intervention 2009;5:255–264. Conflict of interest: Nothing to report. Received 30 June 2010; Revision accepted 1 July 2010 DOI 10.1002/ccd.22725 Published online 7 October 2010 in Wiley Online Library (wileyonlinelibrary.com). ' 2010 Wiley-Liss, Inc. Catheterization and Cardiovascular Interventions 77:158–159 (2011)