Does a coronary stent reduce the risk of all-cause mortality?

Coronary Stents and All-Cause Mortality

Coronary stents do not significantly reduce all-cause mortality compared to optimal medical therapy in stable coronary artery disease, though they may provide benefits in specific high-risk populations.

Evidence on Mortality Outcomes

Overall Mortality Impact

• According to the most recent evidence, coronary stenting does not demonstrate a significant reduction in all-cause mortality compared to optimal medical therapy in patients with stable coronary artery disease 1
• The NORSTENT trial with 9,013 patients and 6-year follow-up found no significant difference in death from any cause between drug-eluting stents and bare-metal stents (16.6% vs. 17.1%, hazard ratio 0.98) 2
• A meta-analysis of 17 randomized controlled trials including 8,221 patients showed no reduction in total mortality with drug-eluting stents compared to bare-metal stents after 1-4 years of follow-up 3

Mortality in Specific Populations

• In-hospital mortality for elective stent procedures ranges from 0-3.7%, with one-year mortality of 3.4% in low-risk patients 4
• High-risk or emergency cases have significantly higher in-hospital mortality (13.7-45.4%) 4
• Hospital volume impacts outcomes: facilities performing >400 procedures/year have lower mortality rates (1.1%) compared to lower-volume centers (1.5%) 4

Factors Affecting Mortality After Stenting

Patient-Related Risk Factors

• Independent predictors of increased mortality after stenting include 5:
  • Ejection fraction <50% (RR 4.1)
  • Multivessel disease (RR 3.0)
  • Diabetes (RR 2.9)
  • Implantation in saphenous vein graft (RR 2.1)
  • Unstable angina (RR 1.9)
  • Female sex (RR 1.7)

Stent Type Considerations

• Drug-eluting stents (DES) and bare-metal stents (BMS) show similar overall mortality rates 4, 2
• Some evidence suggests sirolimus-eluting stents may be associated with increased non-cardiac mortality at 2-3 years of follow-up 3
• DES demonstrate lower rates of target vessel revascularization compared to BMS 4

Coronary Artery Bypass Grafting (CABG) vs. Stenting

• CABG may provide mortality benefit over optimal medical therapy in patients with extensive coronary disease (OR = 0.84; 95% CI: 0.71-0.97) 1
• This mortality benefit is particularly evident in patients with left main and/or multivessel disease 1
• CABG is associated with a lower risk of myocardial infarction compared to optimal medical therapy (OR = 0.67; 95% CI: 0.49-0.91) 1

Dual Antiplatelet Therapy (DAPT) Considerations

• Prolonged DAPT beyond 12 months after stent implantation may be associated with increased mortality (21% increase in completed RCTs) 6
• This mortality increase appears to be due to increased non-cardiovascular mortality not offset by reduction in cardiac mortality 6
• The risk-benefit ratio differs by stent type: everolimus-eluting stents (the most commonly used today) showed higher mortality with prolonged DAPT (2.1% vs. 1.1%, p=0.02) 6

Clinical Implications

• For stable coronary artery disease, stenting should not be performed with the primary goal of reducing all-cause mortality
• Stenting remains valuable for symptom relief and reducing repeat revascularization rates 2
• CABG should be considered for mortality benefit in patients with left main and/or multivessel disease 1
• Hospital volume and operator experience are important factors when considering coronary interventions 4
• Careful assessment of patient-specific risk factors is crucial, as mortality is strongly influenced by baseline clinical characteristics 4

Common Pitfalls to Avoid

• Assuming stenting will reduce mortality in all patients with coronary artery disease
• Extending DAPT beyond 12 months without careful consideration of bleeding risks and potential mortality impact
• Underestimating the importance of hospital volume and operator experience on outcomes
• Failing to consider CABG for patients with extensive coronary disease who might derive mortality benefit