CardioExchange Archive

 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.

(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?