Drug-Eluting Stents: A Potential Preemptive Treatment Choice for Vulnerable Coronary Plaques

Abstract

Restenosis, a major limitation of percutaneous transluminal coronary angioplasty, has been dramatically reduced by the use of drug-eluting stents (DES). Because the majority of acute coronary events occur at nonobstructive lesions that are vulnerable, it has been suggested that prophylactic stenting of vulnerable plaques (VP) to prevent further plaque instability, thereby preventing future coronary events, is as a reasonable strategy. The use of DES in treating intermediate coronary lesions has been shown to be safe and effective. Clinical trials evaluating different intracoronary imaging modalities for the detection of VP and to define its association with subsequent coronary events are ongoing. Risk stratification of such intermediate lesions by VP imaging can help to identify appropriate lesions for preemptive treatment in patients who are at high risk for acute coronary events or recurrent events. Such a strategy should help to improve outcomes in these patients. Current limitations of DES include the long-term risk of stent thrombosis and the need for prolonged dual antiplatelet therapy. Several other transcatheter-based approaches for the stabilization of VP to overcome the limitations of DES are under development. These include drug-eluting balloons, bioabsorbable stents, photodynamic therapy, and cyroenergy. These improvements in technology hopefully will reduce or eliminate the long-term risk of stent thrombosis associated with DES, thus shifting the risk-benefit ratio toward prophylactic stenting of nonobstructive VP in the future.