The chief advantage of drug-eluting stents (DES) over bare-metal stents is that they significantly reduce the risk for restenosis. The chief disadvantages of DES are their greater cost and the requirement for prolonged dual antiplatelet therapy after implantation.
In a study published in the Archives of Internal Medicine, Amit Amin and colleagues analyzed data from 1.5 million PCI procedures included in the National Cardiovascular Data Registry (NCDR) CathPCI registry to assess whether a higher risk for target vessel revascularization (TVR) is associated with greater DES use and to estimate the economic impact of less DES use in patients who are at low risk for TVR.
The authors calculated that 43.0% of patients were at low risk for TVR (risk <10%), 43.8% were at moderate risk (risk 10%-20%), and 13.2% were at high risk (risk >20%). DES were used 73.9% of the time in the low-risk group, 78.0% in the moderate-risk group, and 83.2% in the high-risk group. According to the investigators, cutting DES use by half in low-risk patients would lower U.S. healthcare costs by $205 million each year, at the cost of an increase in the overall TVR rate of 0.5%.
The authors conclude that “a strategy of lower DES use among patients at low risk of TVR could present an important opportunity to reduce health care expenditures while preserving the vast majority of their clinical benefit.”
In an invited commentary, Peter W. Groeneveld writes that “the use pattern of DES during the past 9 years illustrates how far away the system is from consistently embracing value-based medical decision making, and it also enumerates the many barriers and inertial practices in US health care that must be surmounted to reach economic sustainability.”
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NEJM — Recent Cardiology Articles
Like the OAT and Courage Trials – interventional cardiologists are just a hard group to re-train.