New trends in the interventional treatment of ischaemic heart disease

Direct revascularization of an ischaemic vascular bed represents an attractive treatment option for patients with coronary artery disease. Coronary artery bypass surgery has been demonstrated to provide both symptomatic improvement and, in certain circumstances, to improve prognosis, while catheter-based techniques offer substantial improvement in symptomatology, with reduced morbidity compared with bypass surgery. Although balloon angioplasty has been associated with lesion success rates approximating to 89%, a number of anatomical substrates have proved refractory to this approach and restenosis remains a significant problem. Newer interventional modalities, such as directional atherectomy, rotablation, transluminal extraction catheterization, laser coronary angioplasty and coronary stenting, all have the potential to offer improved rates of restenosis under specific circumstances. With the exception of stents, most have not been shown to provide an overall improvement in rates of restenosis. Numerous pharmacological agents have also been investigated in an attempt to reduce levels of restenosis. Calcium channel blockers have been assessed in five trials, none of which has demonstrated a conclusive benefit, although meta-analysis of the data generated in these trials has shown a 30% reduction in the likelihood of restenosis associated with their use. More recently, monoclonal antibodies to glycoprotein IIb/IIIa have been linked to a reduction in restenosis.