Aug. 15, 2011 -- Doctors can save the health care system hundreds of millions of dollars annually without increasing patients' risk of heart attack or death by using drug-eluting stents selectively, according to a study published today in the journal Circulation.
Drug-eluting stents, which are coated with clot-preventing medications, were introduced in 2003 and quickly became the treatment of choice for patients whose narrowed arteries required the thin metal tubes to keep blood and oxygen flowing normally. From 2004 to 2006, drug-eluting stents accounted for 92% of stent use.
Then, following FDA concerns that such stents raised the risk of clotting, heart attacks, and death, that figure dropped to 68% in 2007 as doctors began to be much more selective when determining which patients were best suited for drug-eluting stents.
While it turned out that such risks were unfounded, the drastic drop in the number of drug-eluting stent procedures allowed researchers to compare how well patients did when the stents were used in nearly all cases vs. how well they did when the stents were used more conservatively.
"We were curious to understand the clinical impact," says study author David J. Cohen, MD, MSc, director of cardiovascular research at Saint Luke's Mid America Heart and Vascular Institute in Kansas City, Mo. "This is one of the few times anybody had looked at the effectiveness of using drug-eluting stents selectively."
Liberal Stent Use Compared to Selective Use
Cohen and his colleagues examined data from more than 10,000 patients who had undergone an angioplasty with stent placement at 55 medical centers around the country. Angioplasty is the procedure in which a catheter-guided balloon is inserted into a narrowed coronary artery to open it, also known as a percutaneous coronary intervention (PCI). A bare-metal stent or drug-eluting stent is often inserted during the procedure to help hold the artery open.
They found that the rates of heart attack and death were the same, regardless of whether or not the drug-eluting stents had been used selectively. The need for repeat procedures only increased by 1%.
"There's very little downside to using [drug-eluting stents] selectively," Cohen says. "But the benefits to the health care system are quite substantial."
Selectively using drug-eluting stents reduced medical costs by about $400 per person. The authors estimate that, given the nearly 1 million angioplasties performed each year, the practice has saved the health care system about $400 million annually.
Which patients are most likely to benefit from a drug-eluting stent is not a question that this study answered. Further studies will be required to determine that. In the meantime, doctors have been focusing on patients at higher risk of reblockage.
According to cardiologist and American Heart Association spokesman Johnny Lee, MD, president of New York Heart Associates, patients with blood vessels that are 2.5 millimeters or smaller, as well as for those with longer lesions, are most likely to benefit from drug-eluting stents.
Care More Important Than Cost
Lee says it is always a welcome surprise to see a study that shows that a procedure can be practiced more cost-effectively. However, he points out that what will guide doctors is not how much they can save the health care system, but what treatment best suits the individual patient.
"Our decisions are never based on whether or not we are saving the health care system money," Lee says. "You choose what's best for the patient, and if that is a drug-eluting stent, that is what you choose."
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