Over the last 20 years, percutaneous transluminal balloon coronary angioplasty (PTCA), bare metal stents (BMS) and drug eluting stents (DES) succeeded each other as catheter-based treatments for coronary artery disease (CAD). We present an overview of randomised trials comparing these interventions with each other and with medical therapy in patients with nonacute CAD.
We searched Medline for trials contrasting at least two of the aforementioned interventions. Outcomes of interest were death, myocardial infarction (MI), coronary artery bypass grafting (CABG), target lesion or vessel revascularisation (TLR/TVR), and any revascularisation. Random effects meta-analyses summarised head-to-head (direct) comparisons, and network meta-analyses integrated direct and indirect evidence.
61 eligible trials (25 388 patients) investigated 4 of 6 possible comparisons between the 4 interventions. No trials directly compared DES with medical therapy or PTCA. In all direct or indirect comparisons, succeeding advancements in PCI did not yield detectable improvements in deaths and MI. The risk ratio for indirect comparisons between DES and medical therapy was 0·96 (95% confidence interval: 0·60, 1·52) for death and 1·15 (0·73, 1·82) for MI. In contrast, there were sequential significant reductions in TLR/TVR with BMS compared to PTCA and with DES compared to BMS. The risk ratio for the indirect comparison between DES and PTCA for TLR/TVR was 0·30 (0·17, 0·51).
Sequential innovations in the catheter-based treatment of nonacute CAD showed no evidence of an impact on death or MI when compared with medical therapy.