Use of Drug-Eluting Stents Drops Over Past Year
About three-quarters of the drop in DES use at Duke has been in patients who face a problem with long-term aspirin and clopidogrel dosing, Dr. Krucoff said.
The other, smaller part of the DES decline has been in patients who are now seen as more likely to benefit from a BMS instead of a DES. Although some rough definitions of the patients who fall into this category are emerging, cardiologists stress that the choice between a drug-eluting or bare-metal stent is individualized, and involves a discussion with each patient about the risks and benefits.
“We are using BMS more than DES in patients at low risk of restenosis—for example, in patients without diabetes [and/or] with larger vessels—and in short lesions. We tend to reserve DES for patients with a moderate or high risk of restenosis,” said Dr. Peter B. Berger, a cardiologist and associate chief research officer at the Geisinger Medical Center, Danville, Pa.
Dr. Krucoff says that he and his associates now use BMS in vein grafts and in patients with acute ST-elevation myocardial infarction. These are the vessels and lesions with “a histology that's known to be associated with blood clots and where I worry more about endothelial healing,” he said.
Another side of changing stent use has been a modest but discernible decline in total stent use over the past year. The data collected at 75 U.S. hospitals by Goodroe Healthcare Solutions showed that during the first 6 months of 2007, overall use of coronary stents fell by about 8%. This is corroborated by about an 11% fall in sales of all coronary stents, both DES and BMS, reported by manufacturers, said Joane Goodroe in an interview. “This is the first time we've ever seen an overall decrease in interventional cases.” Data from the surveyed hospitals failed to show any change in the rate of coronary artery bypass grafting during this period, added Ms. Goodroe, president of the company.
The downturn in stenting may have been spurred in part by the COURAGE results, which showed that certain patients with stable coronary disease can safely be initially managed with medical treatment only, deferring stenting until the patient or physician decides it's unavoidable. But some cardiologists were skeptical that the results from a single study—even one that had as much media attention as COURAGE—could change practice so quickly. They see a slight reduction in stenting as part of a management trend that began well before last March.
“I think what we're seeing is much more risk factor reduction and use of statins,” said Dr. Neal S. Kleiman, director of the cardiac catheterization laboratory at the Methodist DeBakey Heart Center, Houston. “Physicians used to put patients on trivial doses of statins. Now everyone is on 40 mg or 80 mg of atorvastatin [Lipitor]. I think it will take awhile for the effect of COURAGE to percolate down,” he said in an interview.
“COURAGE addressed a very circumscribed group of patients. [The investigators] screened about 35,000 patients to find about 3,000 eligible patients” with stable coronary disease who had also undergone an angiogram, Dr. King noted. The randomized group was also limited to patients who were rated by their physicians as having the equipoise for immediate treatment with either stenting or medical therapy only. About a third of the patients in the medical arm eventually had stenting during about 4 years of follow-up. “If physicians practiced using the COURAGE strategy, it should reduce stenting, but by just a little bit,” Dr. King said.
“COURAGE hasn't changed how I decide to put in stents, but it's changed a lot of the conversations I have with patients because of the media hype. Patients say, 'Doc, you're not going to put one of those stents in me, are you?'” Dr. Krucoff said.
“COURAGE caused a perfect storm of media attention, because the results came along when concerns about DES were almost peaking,” Dr. Bhatt said. “The combination may have contributed to reduced stent use nationwide. Everyone sees stent use down from a year ago.
“Most patients at academic centers were already being treated in COURAGE fashion, but it might be different in private practice,” Dr. Bhatt continued. “The COURAGE results and concerns about thrombosis may influence referring cardiologists and primary care physicians. They may now think twice about stable patients: Why not try medical therapy first before whisking them to the cath lab?”
For stable patients, 'why not try medical therapy first before whisking them to the cath lab?' DR. BHATT
ELSEVIER GLOBAL MEDICAL NEWS
