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The introduction of drug-eluting stents (DES) in 2002 revolutionised the field of percutaneous coronary intervention (PCI), by significantly reducing rates of restenosis when compared to bare-metal stents (BMS).1 Following this there was a rapid and unprecedented uptake in their use, such that within a matter of years they were used in approximately 80–90% of PCI cases in the USA, while in the UK their use rose by over 300% between 2003 and 2006.2 3This honeymoon period was brought to an abrupt end following the well publicised concerns over their long-term safety that emerged during the ‘Barcelona firestorm’ in 2006.4 The consequences were a global reduction in their use, and only recently have rates of use recovered to what they were.3 It has been 8 years since the introduction of DES, and this would seem an appropriate time to reappraise their current position, and look to the future, as DESs try to maintain their unique position in interventional cardiology practice.
Are DESs effective?
Restenosis, the Achilles heel of both balloon angioplasty and stenting with BMS, with rates in published series of nearly 50% and 25%, respectively, was ultimately one of the driving forces behind the development of DES. The zero percentage restenosis rate published in the pivotal RAVEL study was unlikely to be maintained for all patient groups1; however, there can be little disappointment with the consistently low rates of restenosis observed in patients treated with DES. A large meta-analysis by Stettler et al reported a reduction in target lesion revascularisation (TLR) of 70% (p<0.0001) with sirolimus-eluting stents (SES) and 58% (p<0.001) with paclitaxel-eluting stents (PES) compared to BMS.5 This corresponded to an impressive number needed to treat, to prevent a single revascularisation, of seven and eight patients for SES and PES, respectively. Comparable …