Stenting offers no benefit over optimal medical therapy
MedWire News: Initial coronary stent implantation shows no additional benefit over optimal medical therapy for the prevention of adverse outcomes in stable coronary artery disease (CAD) patients, a meta-analysis shows.
"The findings of this analysis support current recommendations for instituting optimal medical therapy in patients with stable CAD rather than proceeding directly to stent implantation," report Kathleen Stergiopoulos and David Brown from Stony Brook University Medical Center in New York, USA.
Reporting their findings in the Archives of Internal Medicine, Stergiopoulos and Brown identified eight prospective randomized trials that compared initial coronary stent implantation with medical therapy (including aspirin, beta blockers, ACE inhibitors, and statins) among a total of 7229 patients.
Three trials enrolled stable patients after myocardial infarction (MI) and five trials enrolled patients who had stable angina and/or ischemia on stress testing.
Over a mean weighted follow-up of 4.3 years, 649 deaths occurred. Of these 322 (8.9%) occurred in patients who received initial stent implantation, and 327 (9.1%) occurred in those who received initial medical therapy.
Patients who received initial stent implantation were 2.0% less likely than those who received medical therapy to die, but this association was nonsignificant.
Nonfatal MI occurred in 323 (8.9%) of the patients who received stent implantation, and in 291 (8.1%) of those who received medical therapy. Patients who received stent implantation were 12% more likely to experience nonfatal MI, but this association was also nonsignificant.
Overall, 774 (21.4%) of the patients who received a stent initially underwent unplanned revascularization, compared with 1049 (30.7%) of those who received medical therapy initially, with stent patients being 22.0% less likely than medical therapy patients to undergo unplanned revascularization. Again, this association was nonsignificant.
A nonsignificant association was also seen between angina status and initial intervention, where 597 (29%) of the patients who underwent stent implantation experienced persistent angina compared with 669 (33%) of those who received medical therapy, corresponding to a 20% lower likelihood for stent patients to experience angina than medical therapy patients.
Editorialist William Boden (Samuel Stratton VA Medical Center, Albany, New York, USA) agrees that the current study provides no evidence for an enhanced benefit for CAD patients with either stent implantation or optimal medical therapy.
"The inescapable fact is that it is increasingly harder to justify use of [stent implantation] solely for angina relief in such patients - especially as an initial approach to management, and if medical therapy has not been first instituted," he concludes.
MedWire (www.medwire-news.md) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2012
By Piriya Mahendra