Megan Tooley, Cardiovascular Roundtable
Reducing the use of drug-eluting stents (DES) in patients at low risk of restenosis would lead to significant cost savings with minimal increase in target vessel revascularization (TVR), according to a new retrospective analysis of the National Cardiovascular Data Registry (NCDR)-CathPCI published in the Archives of Internal Medicine.
This research contributes to the growing body of evidence supporting a risk-based, individualized approach to utilization of DES versus bare-metal stents (BMS) during percutaneous coronary intervention (PCI).
Significant cost savings from more principled use of drug-eluting stents
Appropriate utilization of percutaneous coronary interventions (PCI) has been a hot topic among cardiovascular leaders over the past few years (and a common topic on this blog). A recent meta-analysis of eight trials published in the Archives of Internal Medicine promises to add more fuel to the debate by suggesting that patients with stable coronary artery disease (CAD) fare no better with PCI than medical management. Rather than sending patients directly to the cath lab, study authors suggest medical therapy as a first line of defense given the lack of benefit found in treating stable CAD with costly interventions.
Overall, the study found no significant difference in the risk of death, nonfatal MI, unplanned coronary revascularization or angina when the two treatments were compared. The meta-analysis combined data from eight contemporary trials such as the COURAGE, OAT, and BARI 2D studies. All told, 7,229 patients were evaluated, half of whom were randomized to receive both PCI and medical therapy, and half of whom were randomly chosen to receive medical therapy alone. Three of the five studies enrolled patients with stable CAD following an MI while the rest enrolled patients with stable angina and/ or ischemia following a stress test.
PCI offers no benefits over medical management of stable CAD
In the evolving discussion over appropriate utilization of percutaneous coronary intervention (PCI), February is already shaping up to be a busy month. To begin, the first focused update to the 2009 Appropriate Use Criteria (AUC) for Coronary Revascularization was released, providing new guidance on the appropriateness of coronary artery bypass graft (CABG) and PCI for various patient indications.
Now, a critique of the AUC, published in the Journal of the American College of Cardiology: Cardiovascular Interventions, is adding more fuel to the fire in the ongoing debate around when a PCI is considered appropriate, and who is making that judgment.
Debate over PCI appropriateness heating up again