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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

    ??40%- 50%

  • 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