{"id":10835,"date":"2011-08-15T16:42:41","date_gmt":"2011-08-15T20:42:41","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=interventional&p=10835"},"modified":"2011-08-18T09:46:45","modified_gmt":"2011-08-18T13:46:45","slug":"drug-eluting-stents-it-pays-to-be-picky","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2011\/08\/15\/drug-eluting-stents-it-pays-to-be-picky\/","title":{"rendered":"Drug Eluting Stents: It Pays To Be Picky"},"content":{"rendered":"

\u00a0Why buy the most expensive stent when the cheaper one works just as well?<\/em> <\/strong><\/p>\n

Two recent studies suggest that a more selective use of stents has merits. <\/strong><\/p>\n

In an analysis of pooled data<\/a> from 4 trials (SPIRIT II-IV and COMPARE) comparing the more-expensive everolimus-eluting stent (EES)\u00a0with the less-expensive paclitaxel eluting stent (PES), Stone\u00a0and colleagues\u00a0identified a substantial interaction between diabetes and stent type\u00a0with regard to\u00a0clinical outcomes after PCI.<\/p>\n

In patients without diabetes, EES were superior to PES\u00a0for 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<\/em><\/strong>. \u00a0In 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.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
<\/td>\n\n

2 Yr Event Rates (%) <\/strong><\/p>\n<\/td>\n

<\/td>\n<\/tr>\n
<\/td>\n\n

EES<\/strong><\/p>\n<\/td>\n

\n

PES<\/strong><\/p>\n<\/td>\n

\n

P<\/em> value<\/p>\n<\/td>\n<\/tr>\n

Non diabetics (n=4911)<\/strong><\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
Death<\/td>\n\n

1.9<\/p>\n<\/td>\n

\n

3.1<\/p>\n<\/td>\n

\n

0.01<\/p>\n<\/td>\n<\/tr>\n

MI<\/td>\n\n

2.5<\/p>\n<\/td>\n

\n

5.8<\/p>\n<\/td>\n

\n

<0.0001<\/p>\n<\/td>\n<\/tr>\n

Stent thrombosis<\/td>\n\n

0.3<\/p>\n<\/td>\n

\n

2.4<\/p>\n<\/td>\n

\n

<0.0001<\/p>\n<\/td>\n<\/tr>\n

Ischemia-driven TLR<\/td>\n\n

3.6<\/p>\n<\/td>\n

\n

6.9<\/p>\n<\/td>\n

\n

<0.0001<\/p>\n<\/td>\n<\/tr>\n

Combined death, MI or TLR<\/td>\n\n

6.2<\/p>\n<\/td>\n

\n

11.4<\/p>\n<\/td>\n

\n

<0.0001<\/p>\n<\/td>\n<\/tr>\n

<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
Diabetics (n=1869)<\/strong><\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
Death<\/td>\n\n

3.9<\/p>\n<\/td>\n

\n

2.9<\/p>\n<\/td>\n

\n

0.88<\/p>\n<\/td>\n<\/tr>\n

MI<\/td>\n\n

4.2<\/p>\n<\/td>\n

\n

4.9<\/p>\n<\/td>\n

\n

0.49<\/p>\n<\/td>\n<\/tr>\n

Stent thrombosis<\/td>\n\n

1.6<\/p>\n<\/td>\n

\n

2.0<\/p>\n<\/td>\n

\n

0.50<\/p>\n<\/td>\n<\/tr>\n

Ischemia-driven TLR<\/td>\n\n

5.5<\/p>\n<\/td>\n

\n

6.1<\/p>\n<\/td>\n

\n

0.60<\/p>\n<\/td>\n<\/tr>\n

Combined death, MI or TLR<\/td>\n\n

10.1<\/p>\n<\/td>\n

\n

10.3<\/p>\n<\/td>\n

\n

0.86<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

(Data from Circulation<\/em> 2011; 124:893.)<\/p>\n

In a separate\u00a0analysis <\/a>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\u00a0because of\u00a0concerns about stent thrombosis). \u00a0During that time, no change in the rate of death or MI was noted, and TLR increased only slightly (4.1% to 5.1%).\u00a0 Importantly, total cardiovascular costs decreased by $401\/patient.\u00a0 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.<\/p>\n

Do you think most interventionalists consider healthcare costs when choosing a stent?<\/em><\/strong><\/p>\n

Should they?<\/em><\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"

\u00a0Why 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)\u00a0with the less-expensive paclitaxel eluting stent (PES), Stone\u00a0and colleagues\u00a0identified a […]<\/p>\n","protected":false},"author":214,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9],"tags":[566,516,331,200,946],"class_list":["post-10835","post","type-post","status-publish","format-standard","hentry","category-interventional-cardiology","tag-bms","tag-cost-effectiveness","tag-des","tag-diabetes","tag-event-registry"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/10835","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/214"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=10835"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/10835\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=10835"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=10835"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=10835"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}