Drug-Eluting Stents

Abstract

“Does it make economic sense to completely abandon a therapy that works well for 85% to 90% of the population for a new therapy costing four times as much to treat a transient health condition with no impact on either death or myocardial infarction?” J.M. Brophy and L.J. Erickson1 Since Andreas Gruntzig performed the first percutaneous coronary intervention (PCI) in 1977,2 the cost-effectiveness of this procedure has engendered major controversy. Debates have erupted over the clinical value and cost-effectiveness of each new device or therapy that has become available. Controversies have arisen regarding the cost of atherectomy, bare metal stents (BMS), brachytherapy, distal protection devices, glycoprotein IIb/IIIa inhibitors, and intravascular ultrasound.3–6 Drug-eluting stents (DES) are the most recent devices to have their cost scrutinized.7–12 Response by Ryan and Cohen p 1754 Balloon angioplasty is associated with restenosis rates of 30% to 40%, whereas PCI with BMS is associated with rates of 20% to 30%,13,14 and PCI with DES is associated with rates in the single digits.15,16 My colleagues and I pooled the results of 11 DES trials involving >5000 patients using a hierarchical Bayesian random-effects model.17 We found that, compared with BMS, DES reduce angiographic restenosis from 29.3% to 8.9% (Table 1 and Figure 1). There was no difference between DES and BMS in terms of mortality (0.9% versus 0.9%, respectively) or myocardial infarction (2.7% versus 2.9%, respectively). There was a suggestion that restenosis was less with sirolimus-eluting stents (SES) compared with polymeric paclitaxel-eluting stents (PES) (6.2% for SES versus 36.9% for BMS; 7.1% for PES versus 23.5% for BMS), a finding that was subsequently identified in another meta-analysis.18 View this table: TABLE 1. Clinical Events and Restenosis Rates in Randomized Clinical Trials Investigating DESs Figure 1. Forest plot comparing rates of angiographic restenosis for …