TECH: Are stents a waste of money? Maybe

This takes me back to one of my favorites. Two years ago a Stanford study suggested that we should dump the stents and have a by-pass instead, because they were more cost-effective. Stents only delayed the need for by-pass surgery. At the time I was poo-poohed by a couple of cardiologists who told me that it was all different now that we had drug-eluting stents. There wouldn’t be the restenosis that had made earlier bare metal stents in-effective. And indeed the drug-eluting stents have been so effective that their success has actually been a little too much for Boston Scientific to handle! It’s made so much money of its stents that its stock has fallen as Wall Street doesn’t believe that it can pull a smash hit like its Taxus stent off again!

But now with Medtronic introducing its new stent, some studies are emerging that question the value of the drug eluting stents. Last week’s news was that:

A study released at this week’s meeting, one of the largest clinical gatherings in Europe, indicates that drug-coated stents made by J&J and Boston Scientific aren’t cost-effective for all patients and should be restricted to those at highest risk for heart attack. The study will be released in the British medical journal Lancet on Saturday. In the study of 826 patients undergoing angioplasty, researchers from the University of Basel in Switzerland said that the higher cost of drug-coated stents was not compensated for by lower follow-up costs.

Although patients who received drug-coated devices experienced fewer heart attacks and deaths than those who were given the bare-metal variety, the added cost of avoiding one major complication using the drug-coated device was the equivalent of $22,815, the researchers said.

Of course as one technology strikes out, the new one is always there to replace it.

Fridley-based Medtronic Inc. gathered steam over the weekend after releasing two studies that claim its version of the device, called Endeavor, is durable over longer follow-up periods and shows no indication of clotting. After Endeavor received European regulatory approval on July 29, Medtronic launched the device in 75 countries worldwide, with a U.S. introduction anticipated in 2007.

But then later in the week yet another study came out in the NEJM suggesting that minor heart attacks do equally well with drugs as opposed to stents.

In a study colliding with established practice, recovery from small heart attacks went just as well when doctors gave cardiac drugs time to work as when they favored quick, vessel-clearing procedures. The surprising Dutch finding raises questions over how to handle the estimated 1.5 million Americans annually who have small heart attacks – the most common kind. Most previous studies support the aggressive, surgical approach. "I think both strategies are more or less equivalent. I think it is more a matter of patient preference, doctor preference, logistics and, in the long run, it could be a matter of cost," said the Dutch study’s lead researcher, Dr. Robbert J. de Winter of the University of Amsterdam.

Let’s hope for the sake of Boston Scientific, J&J, Medtronic and invasive cardiologists across this great land that no one from CMS or an insurance company reads the New England Journal! Although to be fair, the drugs they used to combat the heart attack weren’t exactly cheap anyway.

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  1. Another article in NEJM earlier this year that was based on retrospective data from New York and covered a very large number of stent placements versus coronary by-pass showed by pass to offer better protection agaist future heart attacks than stenting. The reason behind this remains speculative, but the editorial in the same issue suggested that during by-pass other potentially dangerous lesions are by-passed before they can cause a heart attack. Conversely, during stenting only the lesion that causes the patients current symptoms is treated (angina). As a surgeon, I do find this hypothesis very compelling and it may fly in the face of stenting being used to prevent heart attacks for one other reason: lesions that cause heart attacks cannot be identified with certainty and therefore cannot be stented. Furthermore, no stent currently exists that can treat these lesions as the ‘heart attack lessions’are very different from those treated today.

  2. Well my father’s case of angioplasty and stenting must be the exception. He has outlived the twenty year mark since his MI without a bypass or another MI.
    Maybe your analysis is entirely a monetary one?

  3. As a participant in at a number of the companies and institutions; I have learned several things. Cardiologist have always been envious of the income and prestige that the Cardiovascular surgical side of the house acquired. Stents were a break through for them in this regard, drug-eluting or otherwise. Drug companies and Bio-Tech companies will always compete, especially in study funding, for market share. It’s about marketing not medicine. Benificial studies are always touted by the marketing departments and contrarian studies are ignored.

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