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ARTICLE

Evidence for Use of Coronary Stents: A Hierarchical Bayesian Meta-Analysis

James M. Brophy, MD, PhD; Patrick Belisle, MSc; and Lawrence Joseph, PhD

20 May 2003 | Volume 138 Issue 10 | Pages 777-786

Background: Coronary stents are widely used in interventional cardiology, but a current quantitative systematic overview comparing routine coronary stenting with standard percutaneous transluminal coronary angioplasty (PTCA) and restricted stenting (provisional stenting) has not been published.

Purpose: To summarize results from all randomized clinical trials comparing routine coronary stenting with standard PTCA.

Data Sources: Electronic databases were searched by using the key words angioplasty and stent. References from identified articles were also reviewed. In addition, several prominent general medical and cardiology journals were searched and agencies known to perform systematic reviews were consulted.

Study Selection: All comparative randomized clinical trials were included, except those involving primary angioplasty for the treatment of acute myocardial infarction.

Data Extraction: A specified protocol was followed, and two of the authors independently extracted the data. Outcomes assessed were total mortality, myocardial infarction, angiographic restenosis, coronary artery bypass surgery, repeated PTCA, and freedom from angina.

Data Synthesis: The results were synthesized by using a Bayesian hierarchical random-effects model. A total of 29 trials involving 9918 patients were identified. There was no evidence for a difference between routine coronary stenting and standard PTCA in terms of deaths or myocardial infarctions (odds ratio, 0.90 [95% credible interval (CrI], 0.72 to 1.11]) or the need for coronary artery bypass surgery (odds ratio, 1.01 [CrI, 0.79 to 1.31]). Coronary stenting reduced the rate of restenosis (odds ratio, 0.52 [CrI, 0.37 to 0.69]) and the need for repeated PTCA (odds ratio, 0.59 [CrI, 0.50 to 0.68]). The trials showed a wide range of crossover rates from PTCA to stenting. By use of a multiplicative model, each 10% increase in crossover rate decreased the need for repeated angioplasty by approximately 8% (odds ratio multiplying factor, 1.08 [CrI, 0.98 to 1.18]). Routine stenting probably reduces the need for repeated angioplasty by fewer than 4 to 5 per 100 treated persons compared with PTCA with provisional stenting. Studies were not blinded and suggest a bias with a possible overestimation of this benefit.

Conclusions: In the controlled environment of randomized clinical trials, routine coronary stenting is safe but probably not associated with important reductions in rates of mortality, acute myocardial infarction, or coronary artery bypass surgery compared with standard PTCA with provisional stenting. Coronary stenting is associated with substantial reductions in angiographic restenosis rates and the subsequent need for repeated PTCA, although this benefit may be overestimated because of trial designs. The incremental benefit of routine stenting for reducing repeated angioplasty diminishes as the crossover rate of stenting with conventional PTCA increases.

Editors' Notes Context Although expensive, coronary stents are routinely used in angioplasties. However, are they better than balloon angioplasty? Contribution This meta-analysis of 29 randomized trials found that routine stenting reduced restenosis rates as compared with provisional stenting but did not affect rates of mortality or myocardial infarction or the need for bypass surgery. Routinely using stents instead of angioplasty with bailout stents for complications of or unsatisfactory results from angioplasties (provisional stenting) reduced the need for repeated revascularization procedures by at most 5 per 100 treated patients. Implications The benefits of routine stents versus angioplasty with provisional stents are modest. Cautions Effects may vary depending on the lesions and vessels that are treated. Trials did not test new drug-eluting stents. –The Editors

 

Author and Article Information

From McGill University, Montreal, Quebec, Canada.

Grant Support: Dr. Brophy was supported by Les Fonds de la Recherche en Santé du Québec and Dr. Joseph by the Canadian Institutes of Health Research.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: James Brophy, MD, PhD, Division of Epidemiology, McGill University Health Center (MUHC), Royal Victoria Hospital, 687 Pine Avenue West, Room 4.12, Montreal, Quebec H3A 1A1, Canada; e-mail, james.brophy{at}mcgill.ca.

Current Author Addresses: Dr. Brophy: Division of Epidemiology, McGill University Health Center (MUHC), Royal Victoria Hospital, 687 Pine Avenue West, Room 4.12, Montreal, Quebec H3A 1A1, Canada.

Mr. Belisle and Dr. Joseph: Division of Clinical Epidemiology, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada.

Author Contributions: Conception and design: J.M. Brophy, L. Joseph.

Analysis and interpretation of the data: J.M. Brophy, P. Belisle, L. Joseph.

Drafting of the article: J.M. Brophy, L. Joseph.

Critical revision of the article for important intellectual content: J.M. Brophy, P. Belisle, L. Joseph.

Final approval of the article: J.M. Brophy, P. Belisle, L. Joseph.

Statistical expertise: J.M. Brophy, P. Belisle, L. Joseph.

Obtaining of funding: J.M. Brophy.

Administrative, technical, or logistic support: J.M. Brophy

Collection and assembly of the data: J.M. Brophy, L. Joseph.

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