Drug-eluting coronary stents: many meta-analyses, little benefit.
(1) Angioplasty is one method of unblocking a stenosed coronary artery. A metal stent is sometimes placed in the vessel lumen. Drug-eluting stents coated with an immunosuppressant or cytotoxic drug have been developed with the objective of reducing the risk of recurrent stenosis; (2) We examined the available literature on the efficacy and adverse effects of drug-eluting stents, based on the standard Prescrire methodology; (3) We found a plethora of clinical trials of drug-eluting stents, and numerous meta-analyses, reflecting the broad economic implications of the market for these devices. Yet drug-eluting stents appear to be no more effective than bare metal stents in reducing overall morality, cardiac mortality, the risk of myocardial infarction, or stent thrombosis. Few follow-up data are available beyond 4 years; (4) Revascularisation of the treated coronary artery was about half as frequent with drug-eluting stents as with bare metal stents. However, the apparent advantage is difficult to quantify because in some trials the decision to re-operate was based solely on angiographic criteria, leading to more frequent revascularization. Sirolimus-eluting stents appear to be slightly more effective than paclitaxel-eluting stents in terms of the revascularisation rate; (5) In contrast, late thrombosis (more than a year after stent placement) seems to be more frequent with drug-eluting stents than with bare metal stents. This risk can be reduced by long-term antiplatelet treatment (with clopidogrel plus aspirin), but the benefit is offset by the accompanying increased risk of severe haemorrhagic events. Serious allergic reactions have also been reported; (6) In most cases, especially when the risk of restenosis is low or moderate, it is better to use a bare metal stent. Coronary artery bypass grafting should be considered when there is a high risk of restenosis. Drug-eluting stents are just one alternative to surgery.
D000789:Angina, Unstable / Q000601:surgery; D000800:Angioplasty, Balloon; D015906:Angioplasty, Balloon, Coronary / Q000295:instrumentation; D002986:Clinical Trials as Topic; D020099:Coated Materials, Biocompatible / Q000627:therapeutic use; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D023903:Coronary Restenosis / Q000517:prevention & control*; D023921:Coronary Stenosis / Q000601:surgery*; D054855:Drug-Eluting Stents / Q000009:adverse effects; D006801:Humans; D006967:Hypersensitivity; D015201:Meta-Analysis as Topic; D009203:Myocardial Infarction; D009204:Myocardial Revascularization / Q000295:instrumentation / Q000379:methods; D017239:Paclitaxel / Q000627:therapeutic use*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D020123:Sirolimus / Q000627:therapeutic use*; D013927:Thrombosis / Q000517:prevention & control; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives; D016896:Treatment Outcome
D020099:Coated Materials, Biocompatible; D010975:Platelet Aggregation Inhibitors; D013988:Ticlopidine; D017239:Paclitaxel; D020123:Sirolimus