Drug-coated balloon versus drug-eluting stenting coronary angioplasty for ST-elevation myocardial infarction: a systematic review and meta-analysis of real-world studies
Authors: Ohn M , Lim P , Luen N P 
Published: May 2024

Abstract

Funding Acknowledgements
None.

Introduction
In the realm of ST-elevation myocardial infarction (STEMI), drug-eluting stent angioplasty (DES) is a well-established strategy for urgent revascularization. However, several challenges arise when selecting stents for these patients. These challenges include dealing with endothelial oedema and vasospasm during acute thrombotic occlusion. Moreover, there are concerns surrounding DES-related complications. These complications include the need for prolonged anti-platelet therapy, which increases the risk of bleeding, late stent thrombosis, and in-stent restenosis (ISR). In light of these issues, drug-coated balloons (DCB) have emerged as a compelling alternative.
Purpose: This study aims to explore the safety and efficacy of DCB compared to conventional DES angioplasty in the management of STEMI.

Methods
A systematic literature search was conducted across electronic databases (PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, reference lists of relevant publications, and grey literature sources) for studies published from the inception of DCB up to 31st August 2023.

Results
Nine eligible studies, consisting of four randomised controlled trials and two retrospective propensity-matched studies, were included. These studies, all single-center, involved a total of 2,122 patients (934 in the DCB versus 1,188 in the DES group) over a median follow-up period of 15 months (ranging from 6 to 36 months). The meta-analysis showed no statistically significant differences between DCB and DES angioplasty in terms of technical success (OR: 1.82, 95% CI: 0.22-15.08, p = 0.58), major adverse cardiovascular events (MACE) (OR: 1.24, 95% CI: 0.60–2.56, p = 0.57), all-cause mortality (OR: 1.20, 95% CI: 0.83–1.75, p = 0.33), cardiac death (OR: 1.40, 95% CI: 0.47-4.17, p = 0.54), cardiovascular-related hospitalization (OR: 0.72, 95% CI: 0.32-1.65, p = 0.44), recurrent myocardial infarction (OR: 0.99, 95% CI:0.34-2.90, p = 0.99), target lesion revascularization (OR: 1.15, 95% CI: 0.56–2.34, p = 0.71), late luminal loss (SMD: -0.25mm, 95% CI: -1.05 to 0.54, p = 0.53), postoperative TIMI flow (OR: 1.16, 95% CI: 0.54-2.50, p = 0.71), fractional flow reserve (MD: 0.012, 95% CI -0.018 to 0.032, p = 0.27), and bleeding risk (7.2% in DCB versus 7.5% in DES). It's noteworthy that 8.2% of patients in the DCB group required bailout stenting due to coronary artery dissection type C, a rate 10 times higher than that in the DES group (p &lt; 0.005). Additionally, DCB angioplasty displayed a statistically significant presence of residual stenosis compared to DES angioplasty (OR: 6.48, 95% CI: 1.13-37.2, p = 0.04).

Conclusion
DCB angioplasty demonstrates promise but presents unique challenges in STEMI management, particularly in complex scenarios requiring bailout stenting and residual stenosis. The study contributes to the ongoing discussion about the role of DCBs in optimizing STEMI treatment, highlighting their potential benefits and areas of concern.