ArticlesPercutaneous coronary interventions for non-acute coronary artery disease: a quantitative 20-year synopsis and a network meta-analysis
Introduction
Since its introduction by Andreas Gruntzig in 1977, percutaneous coronary intervention (PCI) has revolutionised the care of patients with coronary artery disease by allowing a catheter-based approach to revascularise coronary arteries that are haemodynamically compromised. In the USA, more than a million patients are treated with PCI every year, often for non-acute coronary artery disease.1
Meta-analyses2, 3 suggest that PCI improves outcomes in high-risk patients with acute coronary syndromes and ST-elevation myocardial infarction. However, their role in the management of patients with non-acute coronary artery disease has been controversial. An early meta-analysis4 suggested percutaneous transluminal balloon coronary angioplasty (PTCA) was better than medical therapy for symptom reduction, albeit with an increase in the rate of subsequent procedures. Later trials tested bare-metal stents (BMS) against PTCA,5 and subsequently drug-eluting stents (DES) against BMS.6, 7 On the basis of these trial results, which showed sequential reductions in the need for target vessel or lesion revascularisation with these technological advances, PCI is now done almost exclusively with stents, most of which are drug eluting in the USA.8
Despite the sequential testing of PTCA versus medical therapy, BMS versus PTCA, and DES versus BMS, the cumulative benefits of technological innovations after 20 years of clinical trials in this area have not been systematically assessed. We undertook a systematic overview of all randomised controlled trials comparing medical therapy, PTCA, BMS, and DES in the treatment of patients with non-acute coronary artery disease. We explored the succession of these interventions over time with traditional meta-analysis and network meta-analysis.9, 10
Section snippets
Literature search
We undertook three incremental electronic Medline searches with the MeSH terms “stents”, “angioplasty”, and “coronary disease” (last search April 28, 2008) to identify English language publications from randomised controlled trials assessing medical therapy, PTCA, BMS, or sirolimus-eluting or paclitaxel-eluting stents (DES) in patients with coronary artery disease. We used a methodological filter to select controlled trials.11 We complemented searches by perusing the reference lists of previous
Results
The electronic searches yielded 2559 citations, which were screened reading the abstract of each. Of these publications, 91 were reviewed in full, and 61 trials (described in 72 publications) were eligible for our comparative effectiveness overview (webappendix pp 1 and 3–6). Two trials (one comparing PTCA vs medical treatment in strata of patients with one-vessel and two-vessel disease,18 and one comparing slow and moderate release paclitaxel-eluting stents vs BMS19) were entered as four
Discussion
Over the past two decades, more than 25 000 patients were enrolled in 61 randomised controlled trials (63 meta-analysis entries) testing PCI for the treatment of non-acute coronary artery disease. Although BMS and DES yielded sequential improvements in reducing the need for revascularisation, we noted no evidence that serial innovations in PCI technologies yielded detectable improvements in the outcomes of death or myocardial infarction compared with medical therapy. Overall, these results lend
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