CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

August 15th, 2011

Drug Eluting Stents: It Pays To Be Picky

and

 Why buy the most expensive stent when the cheaper one works just as well? 

Two recent studies suggest that a more selective use of stents has merits. 

In an analysis of pooled data from 4 trials (SPIRIT II-IV and COMPARE) comparing the more-expensive everolimus-eluting stent (EES) with the less-expensive paclitaxel eluting stent (PES), Stone and colleagues identified a substantial interaction between diabetes and stent type with regard to clinical outcomes after PCI.

In patients without diabetes, EES were superior to PES for the incidence of death, MI, stent thrombosis, and ischemia-driven target lesion revascularization (TLR) during the 2 years after stent implantation; in contrast, no significant differences in safety or efficacy outcomes were present in diabetic patients.  In fact, in diabetics treated with insulin, the 2-year rate of ischemia-driven TLR was higher with EES than with PES, whereas the opposite trend was observed in those not treated with insulin.

2 Yr Event Rates (%)

EES

PES

P value
Non diabetics (n=4911)
Death

1.9

3.1

0.01
MI

2.5

5.8

<0.0001
Stent thrombosis

0.3

2.4

<0.0001
Ischemia-driven TLR

3.6

6.9

<0.0001
Combined death, MI or TLR

6.2

11.4

<0.0001
Diabetics (n=1869)
Death

3.9

2.9

0.88
MI

4.2

4.9

0.49
Stent thrombosis

1.6

2.0

0.50
Ischemia-driven TLR

5.5

6.1

0.60
Combined death, MI or TLR

10.1

10.3

0.86

(Data from Circulation 2011; 124:893.)

In a separate analysis of 10,144 PCI patients enrolled in the Evaluation of Drug Eluting Stents and Ischemic Events (EVENT) registry, investigators found that DES use decreased from 92% to 68% from 2004 to 2007 (largely because of concerns about stent thrombosis).  During that time, no change in the rate of death or MI was noted, and TLR increased only slightly (4.1% to 5.1%).  Importantly, total cardiovascular costs decreased by $401/patient.  With nearly 1 million PCI procedures performed annually in the United States, adoption of a more selective DES strategy could result in ~$400 million/year in annual cost savings to the U.S. healthcare system.

Do you think most interventionalists consider healthcare costs when choosing a stent?

Should they?

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2 Responses to “Drug Eluting Stents: It Pays To Be Picky”

  1. Robert Hennessy, MD says:
    August 15, 2011 at 8:07 pm

    No. Maybe.

    Competing interests pertaining specifically to this post, comment, or both:
    None

  2. izaskun obieta fresnedo, MB, MPH says:
    August 21, 2011 at 3:05 pm

    no. yes!

    Competing interests pertaining specifically to this post, comment, or both:
    none