[Interventional cardiology in 2005]

Drug-eluting stents have been shown to reduce the rate of restenosis significantly in all types of lesion, patient and clinical context without increasing thrombotic complications. Although their high cost limits the extent to which they can replace bare-metal stents, their use will increase inexorably in coming years. In addition to stents containing sirolimus and paclitaxel, which have already been approved, two additional drug-eluting stents have appeared on the market this year: one elutes tacrolimus and the other, ABT578 (a rapamycin analogue). Now that the restenosis rate has been dramatically reduced, the main limitations on percutaneous coronary intervention (PCI) stem from problematic lesions such as those at bifurcations and chronic total occlusions. Although these lesions can be tackled more often and more successfully than in the past, the results obtained are very different from those achieved with other types of lesion. With improvements in safety and long-term efficacy, the number of indications for PCI has expanded to include patients with multivessel disease, left main coronary artery disease, left ventricular dysfunction, and diabetes, conditions in which surgical revascularization was thought necessary only a few years ago. Acute coronary syndromes now make up an increasing proportion of indications for PCI, both in absolute and relative terms. One future challenge is the early identification and treatment of vulnerable plaques before they manifest clinically in the form of irreversible complications such as sudden death or acute myocardial infarction. The use of multislice computed tomography, such as 64-slice detector systems, has considerably increased the sensitivity, specificity, and positive and negative predictive values of diagnosis to around 90%, though diagnostic accuracy may be considerably less in patients with severe coronary calcification, stents, or cardiac arrhythmias. Although the technique is straightforward for patients, the image reconstruction process is time-consuming, few centers currently offer the technique, and radiation exposure is several times that with conventional invasive coronary angiography. It appears that the main application of the technique is in ruling out coronary disease in low-risk patients rather than being part of the diagnostic work-up in those with a high probability of coronary artery disease.