122 drug eluting stents
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Drug Eluting Stents
The Wrong therapy for Vulnerable PlaqueRS SchwartzMinneapolis Heart Institute
A 3-Part ArgumentThere are no data yetVP Detection and EconomicsThe Strategy is wrong
FACTDrug Eluting stents appear to form a healthy neointimaThe restenosis rate may be 8-10%
FACTLong term results are pendingWe have no data for mild disease or Vulnerable lesions
Argument #1There is simply no evidence that the drug eluting stent will fix the vulnerable plaque problem.
FACTDrug Eluting stents will initially cost about $3,000 each.
FACTSensitivity and Specificity for Detection are unknown but will likely be poor
FACTIf a typical patient has 3-4 such plaques, a single session will cost $12,000 in stents alone
FACTIncluding all asymptomatic patients, there may be 2,000,000 candidates. At $12,000 each, this will be $24,000,000,000 in stents alone
Argument #2Stenting every vulnerable plaque will break the National Budget.Which Lesions to stent and which to ignore?
FactVulnerable Plaque is a multifocal and possibly diffuse disease
FactVulnerable Plaque is a systemic disease
Multicentric inflammation in epicardial coronary arteries of patients dying of acute myocardial infarction.Spagnoli LG, Bonanno E, Mauriello A, Palmieri G, Partenzi A, Sangiorgi G, Crea F.
J Am Coll Cardiol 2002 Nov 6;40(9):1579-88
Spagnoli et al3 Groups, Autopsy ptsAcute MIOld MINo CADCell Suspensions of all 3 coronary arteries
Spagnoli et alFlow CytometryLymphocytesSMCCD3/CD68
Spagnoli et alResultsDiffuse lymphoctye activation in all 3 arteries of Acute MI patients
Patient 4, Stable, NZMaxT Difference Map of RCA0.05.1.15.2.25MaxTdiffDistal MID Prox
FactWe just spent 12 years developing Drug Eluting Stents as a LOCAL therapy
FactRoxs own data argues against stents
The 1 year recurrent MACE in Acute Coronary Syndromes with PCI may be as high as 20%
RhetoricTreating a systemic disease with a local therapy makes no sense.
Argument #3It is folly to treat a diffuse problem with a focal therapy.We must instead develop simple therapies for the entire coronary tree.
Shootem all boys, the Devil will sort them outClint Eastwood, 1972
StrategyRearrange the cellular mileu of the entire coronary tree.Treat the disease, not the lesions.
Summary1. No efficacy data in mild/minimal disease2. We cant afford to treat with Drug Eluting Stents3. It is folly to treat a diffuse problem with a focal therapy.
AxiomIn any debate, present your case simply and cogently.Then personally savage your opponent.
PositionsPhotographsMotherhoodLennox Hill HospIranian