english.prescrire.org > Spotlight > Archives : 2009 > Drug-eluting coronary stents: many meta-analyses, little benefit

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Drug-eluting coronary stents:
many meta-analyses, little benefit

FEATURED REVIEW Drug-eluting stents have been developed with the objective of reducing the risk of recurrent stenosis. We examined the available literature, based on the standard Prescrire methodology. Drug-eluting stents appear to be no more effective than bare metal stents in reducing overall mortality, cardiac mortality, the risk of myocardial infarction, or stent thrombosis.
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Abstract

  • 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.
  • We examined the available literature on the efficacy and adverse effects of drug-eluting stents, based on the standard Prescrire methodology.
  • 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 mortality, cardiac mortality, the risk of myocardial infarction, or stent thrombosis. Few follow-up data are available beyond 4 years.
  • Revascularisation of the treated coronary artery was about half as frequent with drug-eluting stents as with bare metal stents. However, this 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 revascularisation. Sirolimus-eluting stents appear to be slightly more effective than paclitaxel-eluting stents in terms of the revascularisation rate.
  • 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.