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Clinical Evaluation of Angioplasty Versus Stenting and Bare-Metal Stenting Versus Drug-eluting Stenting in the Treatment of Coronary Artery Disease Andrew Rendoff, PA-S, Richard D. Muma, PhD, MPH, PA-C Department of Physician Assistant College of Health Professions, Wichita, Kansas • • • • INTRODUCTION This study focused on the efficacy of angioplasty and stenting in the treatment of coronary artery disease (CAD). Over the past twenty-five years, the concepts of percutaneous transluminal coronary angioplasty (PTCA) and stenting have become dominant modalities in the treatment of CAD. In the late 1970’s and early 1980’s, PTCA was seen as the best possible alternative to bypass surgery until repetitive treatments [1] were required to reopen occluded arteries. Following the failure of PTCA, stenting and derivatives of stenting with drug-eluting compounds have been developed to examine the most effective revascularization technique to reduce the rate of coronary restenosis. The purpose of this study was to perform a systematic examination of the literature to evaluate these techniques and determine the most effective treatment for patients with CAD. RESULTS • Thirty-seven articles met the inclusion criteria and were reviewed for accuracy and applicability. • Analysis of the included articles revealed an abundance of information supporting the efficacy of PTCA with stenting, but insufficient evidence to conclude whether drug-eluting stenting is more effective than bare-metal stenting (Figure 1). Figure 1 • While the current literature available to medical practitioners is quite extensive, there is yet to be a distinct answer to the treatment of choice for patients with CAD. • From this study, the clinical application of interventional stenting is recommended versus angioplasty alone.[1] • Additionally, while drug-eluting stents may be more effective in reducing re-stenosis and the subsequent need for re-intervention, safety concerns (i.e. increased risk of stent thrombosis, aneurysm, and further myocardial infarction) prevent the researchers to conclude whether drug-eluting or bare-metal stents [2-3] are more effective in treating CAD. • Percentages of each technique supported by current research is visible is Figure 2. • Evaluation of the articles revealed: 51.4% of the articles were level 1, 13.5% level 2, and 35.1% were level 3. • Overall grade of recommendation from the evidence was a B.[4] CONCLUSIONS After evaluation of the current research concerning the interventional treatment of CAD, the conclusion exists that PTCA with stenting is more efficacious than PTCA alone, yet no conclusion may be made concerning if drug-eluting stenting is more efficacious than bare-metal stenting due to safety concerns seldom seen with baremetal stents. After evaluating the evidence in the literature, the overall grade of evidence for this project was a B. The best and safest treatment for patients with CAD is PTCA with stenting with insufficient evidence to conclude which stent type is more efficacious.[3] 37 total articles, one paper addresses more than one topic. METHODS • Articles used included randomized controlled clinical trials of adults ranging from 50 to 75 years of age who had undergone either angioplasty or stenting from the years 1979 to 2006. • Key variables evaluated through the Medline database included angioplasty, stenting, and drug-eluting stents. DISCUSSION Figure 2. Results (Percent) 100 90 80 70 60 50 REFERENCES 40 30 20 10 0 PTCA with Stenting PTCA alone Drug-Eluting Stenting Bare-Metal Stenting 1. Mehran R, Dangas G, Abizaid A, Lansky A, Mintz G, Pichard A, Satler L, Kent K, Waksman R, Stone G, Leon M. Treatment of focal in-stent restenosis with balloon angioplasty alone versus stenting: Short- and long-term results. The American Heart Journal. 2001 April: 141: 610-614. 2. Lagervist B, James S, Stenestrand U, Lindback J, Nilsson T, Wallentin L. Long-term Outcomes with Drug-eluting Stents versus Bare-metal Stents in Sweden. NEJM. 2007: 356: 1009-19. 3. Kastrati A, Mehilli J, Pache J, Kaiser C, Valgimigli M, Kelbaek H, Menichelli Sabate M, Suttorp M, Baumgart D, Seyfarth M, Pfisterer M, Schomig A. Analysis of 14 Trials Comparing SirolimusEluting Stents with Bare-metal Stents. NEJM. 2007: 356: 1030-9. 4. Sackett D, Straus S, Richardson W, Rosenberg W, Haynes (2000). How to Practice and Teach EBM. Evidence-Based Medicine.