Does a coronary stent reduce all-cause mortality?

Coronary Stents Do Not Reduce All-Cause Mortality in Stable Coronary Artery Disease

Coronary stents do not reduce all-cause mortality in patients with stable coronary artery disease, as confirmed by multiple high-quality studies and guidelines. 1 The American College of Cardiology explicitly recommends against performing stenting with the primary goal of reducing all-cause mortality in patients with stable coronary artery disease.

Evidence on Mortality Outcomes

Stents vs. Medical Therapy

• In stable coronary artery disease, no stent type has been associated with a reduction in all-cause mortality compared to optimal medical therapy 2
• The NORSTENT trial with 9,013 patients followed for 6 years found no significant difference in death from any cause between drug-eluting stents and bare-metal stents (16.6% vs 17.1%, HR 0.98) 3
• Drug-eluting stents and bare-metal stents show similar overall mortality rates, although drug-eluting stents demonstrate lower rates of target vessel revascularization 1

Stents vs. CABG

• For mortality benefit in patients with left main and/or multivessel disease, CABG should be considered over stenting 1
• CABG has been shown to reduce the risk of mortality compared to optimal medical therapy (OR = 0.84; 95% CI: 0.71-0.97), especially in patients with higher extent of coronary artery disease 2

Factors Affecting Mortality with Stents

Procedural Factors

• Hospital volume is inversely related to mortality rates:
  • Hospitals performing >400 procedures/year: 1.1% mortality
  • Hospitals performing <400 procedures/year: 1.5% mortality 1
• In-hospital mortality for elective stent procedures ranges from 0-3.7%, with one-year mortality of 3.4% in low-risk patients 1
• High-risk or emergency cases have significantly higher in-hospital mortality (13.7-45.4%) 1

Patient-Specific Factors

• Mortality is strongly influenced by:
  • Left ventricular function
  • Comorbidities
  • Lesion complexity 1
• Left main coronary artery disease is associated with a one-year mortality of 3.4% for unprotected cases with normal left ventricular function 1
• Bifurcation lesions have a higher risk of target vessel revascularization (13% vs 3% for non-bifurcation lesions) 1

Causes of Death After Stenting

• In patients who undergo PCI with drug-eluting stents, cardiac and non-cardiac causes contribute similarly to mortality 4
• PCI-related death occurs in approximately 1.3% of cases, with stent thrombosis accounting for 1.1% 4
• Non-cardiac deaths include cancer, infection, respiratory failure, and cerebrovascular events 4
• Prolonged dual antiplatelet therapy (DAPT) beyond 12 months after stent implantation may be associated with increased mortality (21% increase in completed RCTs) due to increased non-cardiovascular mortality 1

Clinical Implications

• Stenting should be performed primarily for symptom relief and reducing repeat revascularization rates, not for mortality benefit 1
• For patients with stable coronary artery disease seeking mortality benefit, CABG should be considered over stenting, particularly in those with left main or multivessel disease 1, 2
• When stenting is performed, patients should be referred to high-volume centers when possible due to lower mortality rates 1

In conclusion, while coronary stents are effective for symptom relief and reducing the need for repeat revascularization, they do not confer a mortality benefit in stable coronary artery disease patients. For patients in whom mortality reduction is the primary goal, CABG may be the preferred revascularization strategy, particularly in those with left main or multivessel disease.