122 drug eluting stents
TRANSCRIPT
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Drug Eluting Stents
The Wrong therapy for Vulnerable Plaque
RS SchwartzMinneapolis Heart Institute
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A 3-Part Argument
There are no data yet
VP Detection and Economics
The Strategy is wrong
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FACT
Drug Eluting stents appear to form a healthy neointima
The restenosis rate may be 8-10%
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FACT
Long term results are pending
We have no data for mild disease or Vulnerable lesions
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Argument #1
There is simply no evidence that the drug eluting stent will fix the vulnerable plaque problem.
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FACT
Drug Eluting stents will initially cost about $3,000 each.
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FACT
Sensitivity and Specificity for Detection are unknown but will likely be poor
??40%- 50%
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FACT
If a typical patient has 3-4 such plaques, a single session will cost $12,000 in stents alone
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FACT
Including all asymptomatic patients, there may be 2,000,000 candidates. At $12,000 each, this will be
$24,000,000,000
in stents alone
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Argument #2
Stenting every vulnerable plaque will break the National Budget.
Which Lesions to stent and which to ignore?
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Fact
Vulnerable Plaque is a multifocal and possibly diffuse disease
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Fact
Vulnerable 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
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Spagnoli et al3 Groups, Autopsy pts
Acute MIOld MINo CAD
Cell Suspensions of all 3 coronary arteries
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Spagnoli et alFlow Cytometry
LymphocytesSMCCD3/CD68
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Spagnoli et alResults
Diffuse lymphoctye activation in all 3 arteries of Acute MI patients
11
5.6
0
3
6
9
12
Percent
Acute MI Old MI No CAD
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Patient 4, Stable, NZPatient 4, Stable, NZMaxT Difference Map of RCAMaxT Difference Map of RCA
0
.05
.1
.15
.2
.25
Max
Tdiff
Distal MID Prox
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Fact
We just spent 12 years developing Drug Eluting Stents as a LOCAL therapy
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Fact
Rox’s own data argues against stents
The 1 year recurrent MACE in Acute Coronary Syndromes with PCI may be as high as 20%
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Rhetoric
Treating a systemic disease with a local therapy makes no sense.
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Argument #3
It is folly to treat a diffuse problem with a focal therapy.
We must instead develop simple therapies for the entire coronary tree.
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“Shoot’em all boys, the Devil will sort them out…”Clint Eastwood, 1972
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Strategy
Rearrange the cellular mileu of the entire coronary tree.
Treat the disease, not the lesions.
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Summary
1. No efficacy data in mild/minimal disease
2. We can’t afford to treat with Drug Eluting Stents
3. It is folly to treat a diffuse problem with a focal therapy.
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Axiom
In any debate, present your case simply and cogently.
Then personally savage your opponent.
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Positions
Photographs
Motherhood
Lennox Hill Hosp
Iranian