Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Coronary stenting decreased restenosis after angioplasty

ACP J Club. 1995 Sept-Oct;123:45. doi:10.7326/ACPJC-1995-123-2-045


Source Citation

Rodriguez AE, Santaera O, Larribau M, et al. Coronary stenting decreases restenosis in lesions with early loss in luminal diameter 24 hours after successful PTCA. Circulation. 1995 Mar 1;91:1397-402.


Abstract

Objective

To evaluate the effectiveness of selective coronary stenting after successful percutaneous transluminal coronary angioplasty (PTCA) in patients at risk for restenosis based on findings at quantitative coronary angiography (QCA) 24 hours after PTCA.

Design

Randomized controlled trial with 6-month follow-up.

Setting

Hospital in Argentina.

Patients

66 patients (mean age 56 y, 82% men) who had QCA 24 hours after successful PTCA and > 0.3 mm loss in minimal luminal diameter or > 10% increase in diameter stenosis. Other inclusion criteria were successful PTCA of a de novo lesion, lesions appropriate for coronary stenting, and informed consent. Follow-up was 100%.

Intervention

Patients were allocated to receive a Gianturco-Roubin intracoronary stent plus medical therapy (n = 33) or medical therapy alone (n = 33), which included aspirin, dipyridamole, a calcium channel blocker, and 24 hours of intravenous (IV) heparin and IV nitroglycerin. Patients in the stent group also received IV dextran 40 until sheath removal and heparin until therapeutic prothombin time was achieved with warfarin that was continued for 6 weeks.

Main outcome measures

Rates of angiographic restenosis, in-hospital complications, and length of stay (LOS) and 6-month incidence of death, MI, coronary artery bypass graft (CABG) surgery, or PTCA.

Main results

No in-hospital adverse outcomes occurred in the control group, whereas in the stent group 1 patient (3%) had an MI, 3 (9%) had subacute closures, and 7 (21.2%) had vascular complications. Mean LOS was 7.3 days for the stent group compared with 2.4 days for the control group (P < 0.01). At 6 months, fewer patients in the stent group than in the control group had restenosis (P < 0.001) or need for CABG or PTCA revascularization (P < 0.01) (Table).

Conclusions

Coronary stenting reduced restenosis and the need for repeat revascularization after percutaneous transluminal coronary angioplasty (PTCA) in a select group of patients at risk for restenosis identified by qualitative coronary angiography at 24 hours. Stenting was associated with a higher in-hospital complication rate and longer length of stay than PTCA alone.

Source of funding: Anchorena Foundation.

For article reprint: Not available.


Table. Intracoronary stent plus medical therapy vs medical therapy alone*

Outcomes at 6 mo Stent plus medical therapy Medical therapy alone RRR (95% CI) NNT (CI)
Restenosis 21.2% 75.7% 72% (48 to 86) 2 (1 to 3)
Need for revascularization 21.2% 72.7% 71% (45 to 86) 2 (1 to 4)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Revised commentary

Since this article was first published, the use of stents has grown dramatically and they are now placed in up to 70% of patients (1). Many factors explain the growth in their use. High-pressure inflations and new anticoagulation regimens have reduced both the LOS and access site complications associated with stenting and they are now comparable to what is reported for balloon angioplasty (2). The availability of stents has given health care providers a new tool to use in the management of acute dissection and has led to a decrease in the risk for adverse in-hospital outcomes (3, 4). Perhaps the biggest impetus for their use has been reports from randomized trials (5-10) and most recently from a large regional registry (11), which showed that stenting reduced the risk for restenosis and cardiac events. Routine stenting is not without its skeptics (12), who caution that in-stent restenosis may be more difficult to treat than the restenosis associated with balloon angioplasty; the efficacy of stenting has not been proved in lesions with more complex morphology; stents are expensive; and aggressive balloon angioplasty with provisional stenting may result in outcomes that are as good as, or superior to, routine stenting. Our understanding of when and how to use coronary stents continues to evolve, particularly in this era of platelet IIb/IIIa receptor inhibitors (13), and it is likely that over time we will learn what combinations of devices and medicines will lead to the best outcomes most cost-effectively.

David Malenka, MD
Dartmouth-Hitchcock Medical CenterLebanon, New Hampshire, USA


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