Cost-effectiveness of drug-eluting stents in patients at high or low risk of major cardiac events in the Basel Stent KostenEffektivitäts Trial (BASKET): an 18-month analysis

Comparison of long versus short ("spot") drug-eluting stenting for long coronary stenoses

We compared spot drug-eluting stenting (DES) to full stent coverage for treatment of long coronary stenoses. Consecutive, consenting patients with a long (>20 mm) coronary lesion of nonuniform severity and indication for percutaneous coronary intervention were randomized to full stent coverage of the atherosclerotic lesion with multiple, overlapping stenting (full DES group, n = 90) or spot stenting of hemodynamically significant parts of the lesion only (defined as diameter stenosis >50%; spot DES group, n = 89). At 1-year follow-up, 14 patients with full DES (15.6%) and 5 patients (5.6%) with spot DES had a major adverse cardiac event (MACE; p = 0.031). At 3 years, MACEs occurred in 18 patients with full DES (20%) and 7 patients (7.8%) with spot DES (p = 0.019). Cox proportional hazard model showed that the risk for MACEs was almost 60% lower in patients with spot DES compared to those with full DES (hazard ratio 0.41, 95% confidence interval 0.17 to 0.98, p = 0.044). This association remained even after controlling for age, gender, lesion length, and type of stent used (hazard ratio 0.42, 95% confidence interval 0.17 to 1.00, p = 0.05). In conclusion, total lesion coverage with DES is not necessary in the presence of diffuse disease of nonuniform severity. Selective stenting of only the significantly stenosed parts of the lesion is an appropriate therapeutic alternative in this setting, offering a favorable clinical outcome.

Cost-effectiveness of drug-eluting stents in a US Medicare setting:a cost-utility analysis with 3-year clinical follow-up data

BACKGROUND

There is only limited information about cost-effectiveness of drug-eluting compared with bare metal stents (BMS) over a time horizon of more than 1 year.

METHODS AND RESULTS

We developed a Markov model based on clinical outcome data from a meta-analysis including 17 randomized controlled trials comparing drug-eluting versus BMS with a minimum follow-up of 1 (n = 8221) and a maximum follow-up of 3 years (n = 4105) in patients with chronic coronary artery disease. Costs were obtained as reimbursement rates for diagnosis related groups from the US Centers for Medicare and Medicaid Services. All costs and effects were discounted at 3% annually. All costs are reported in US dollars of the financial year 2007. The incremental effects are 0.002 (95% confidence interval −0.039 to 0.041) quality-adjusted life-years (QALYs) for the sirolimus- and −0.001 (−0.040 to 0.038) QALYs for the paclitaxel-eluting stents (PES). The incremental costs are $2790 for the sirolimus- and $3838 for the PES. The incremental cost-effectiveness ratio is >$1,000,000 per QALY for the sirolimus-eluting stent. PES are dominated by BMS (i.e., less effective and more costly). Among various sensitivity analyses performed, the model proved to be robust.

CONCLUSIONS

Our analysis from a US Medicare perspective suggests that drug-eluting stents are not cost-effective compared with BMS when implanted in unselected patients with symptomatic ischemic coronary artery disease.

3-year follow-up of the SISR (Sirolimus-Eluting Stents Versus Vascular Brachytherapy for In-Stent Restenosis) trial

OBJECTIVES

The aim of this study was to evaluate long-term outcome of patients treated for in-stent restenosis of bare-metal stents (BMS).

BACKGROUND

Treatment of restenosis of BMS is characterized by high recurrence rates. Vascular brachytherapy (VBT) improved outcome although late catch-up events were documented. Drug-eluting stents tested against VBT in this setting were found superior for at least the first year; superiority at longer follow-up is uncertain.

METHODS

We evaluated 3-year outcome of the multicenter SISR (Sirolimus-Eluting Stents Versus Vascular Brachytherapy for In-Stent Restenosis) trial, which randomized patients with restenosis of BMS to either a sirolimus-eluting stents (SES) or VBT.

RESULTS

Target vessel failure (cardiac death, infarction, or target vessel revascularization [TVR]) at 9 months as previously reported was significantly improved with SES. Kaplan-Meier analysis at 3 years documented that survival free from target lesion revascularization (TLR) and TVR continues to be significantly improved with SES: freedom from TLR 81.0% versus 71.6% (log-rank p = 0.018), and TVR 78.2% versus 68.8% (log-rank p = 0.022), SES versus VBT. At 3 years, target vessel failure and major adverse cardiac events (death, infarction, emergency coronary artery bypass grafting, or repeat TLR) remained improved with SES, but did not reach statistical significance. There was no statistically significant difference in definite or probable stent thrombosis (3.5% for SES, 2.4% for VBT; p = 0.758).

CONCLUSIONS

At 3 years of follow-up, after treatment of in-stent restenosis of BMS, patients treated with SES have improved survival free of TLR and TVR compared with patients treated with VBT. Stent thrombosis rates are not different between the 2 groups but are higher than reported in trials of treatment of de novo lesions.

First-in-man use of polymer-free valsartan-eluting stents in small coronary vessels: a comparison to polymer-free rapamycin (2%)-eluting stents

Introduction. Orally administered angiotensin receptor antagonists administered after bare-metal stent implantation and even after drug-eluting stent implantation seem to lower in-stent restenosis rates.Whether valsartan-eluting stents are similarly effective was tested here in a first-in-man trial.

Materials and methods. The efficacy of a polymer-free drug-eluting stent coated with 300 mcg valsartan was compared to a coating with a 2% rapamycin solution in small (≤ 2.5 mm) coronary vessels with and without oral valsartan on the basis of the YUKON Choice stent system (Translumina GmbH, Hechingen, Germany). Fifteen patients (eight males, mean age 64.4±7.7 years) were treated with YUKON Choice valsartan-eluting stents and 30 patients (24 males, mean age 65.7±8.4 years) received YUKON Choice rapamycin-eluting stents. Clopidogrel was given for six months in all patients.

Results. Within the first 30 days, no adverse events occurred in either group. Binary in-stent restenosis rate was 30.8% (four in 13 angiographic controls) in the valsartan-eluting stent group and 35.0% (eight in 20 angiographic controls) in the rapamycin-eluting YUKON Choice stent group. Mean late lumen loss was 0.78±0.53 mm and 0.79±0.58 mm, respectively. Target lesion and target vessel revascularisation rate was 26.6% and 25.0%, respectively. No restenoses in rapamycin-eluting YUKON Choice stents appeared in 12 patients with adjunct oral valsartan administration.

Conclusions. If polymer-free YUKON Choice stents are used in small vessels, valsartan-eluting stents show an identical efficacy as rapamycin-loaded stents. In patients with rapamycin-eluting YUKON Choice stents it seems that the efficacy can be increased by oral valsartan administration.

Long-term safety and efficacy of drug-eluting versus bare-metal stents in Sweden

BACKGROUND

The long-term safety and efficacy of drug-eluting coronary stents have been questioned.

METHODS

We evaluated 47,967 patients in Sweden who received a coronary stent and were entered into the Swedish Coronary Angiography and Angioplasty Registry between 2003 and 2006 and for whom complete follow-up data were available for 1 to 5 years (mean, 2.7). In the primary analysis, we compared patients who received one drug-eluting coronary stent (10,294 patients) with those who received one bare-metal stent (18,659), after adjustment for differences in clinical characteristics of the patients and characteristics of the vessels and lesions.

RESULTS

Analyses of outcome were based on 2380 deaths and 3198 myocardial infarctions. There was no overall difference between the group that received drug-eluting stents and the group that received bare-metal stents in the combined end point of death or myocardial infarction (relative risk with drug-eluting stents, 0.96; 95% confidence interval [CI], 0.89 to 1.03) or the individual end points of death (relative risk, 0.94; 95% CI, 0.85 to 1.05) and myocardial infarction (relative risk, 0.97; 95% CI, 0.88 to 1.06), and there was no significant difference in outcome among subgroups stratified according to the indication for stent implantation. Patients who received drug-eluting stents in 2003 had a significantly higher rate of late events than patients who received bare-metal stents in the same year, but we did not observe any difference in outcome among patients treated in later years. The average rate of restenosis during the first year was 3.0 events per 100 patient-years with drug-eluting stents versus 4.7 with bare-metal stents (adjusted relative risk, 0.43; 95% CI, 0.36 to 0.52); 39 patients would need to be treated with drug-eluting stents to prevent one case of restenosis. Among high-risk patients, the adjusted risk of restenosis was 74% lower with drug-eluting stents than with bare-metal stents, and only 10 lesions would need to be treated to prevent one case of restenosis.

CONCLUSIONS

As compared with bare-metal stents, drug-eluting stents are associated with a similar long-term incidence of death or myocardial infarction and provide a clinically important decrease in the rate of restenosis among high-risk patients.

Temporal changes in coronary revascularization procedures, outcomes, and costs in the bare-metal stent and drug-eluting stent eras: results from the US Medicare program

BACKGROUND

Although drug-eluting stents have been shown to be cost-effective compared with bare-metal stents for select clinical trial patients, whether these findings apply to the general population is unknown.

METHODS AND RESULTS

We used data from the Medicare 5% Standard Analytic Files to compare the practice and outcomes of coronary revascularization (by either percutaneous coronary intervention or coronary artery bypass grafting) in the United States between 2001 (pre-drug-eluting stent era, n=14 362) and 2004 (post-drug-eluting stent era, n=16 374). Between 2001 and 2004, the rate of revascularization increased from 837 to 931 per 100 000, whereas the proportion of patients who underwent percutaneous coronary intervention as an initial revascularization procedure increased from 67.5% to 75.2% (P<0.001). Over a median follow-up period of 25.5 months, no significant changes in mortality were found between 2001 and 2004 (13.8% versus 13.3%, P=0.193). Significant decreases were seen, however, in the incidence of repeat revascularization (17.1% versus 16.0%, P=0.012) and myocardial infarction (10.6% versus 8.5%, P<0.001). Over this same time period, total cardiovascular care costs per revascularized patient decreased by $1680 (95% confidence interval $1164 to $2196, P<0.001) whereas total noncardiovascular costs increased by $2481 per patient (95% confidence interval $1844 to $3118, P<0.001). When the impact of overall procedural volumes was considered, aggregate cost to the Medicare program for cardiovascular services increased by $544 million over the 2-year follow-up period. Risk-adjusted results for both the clinical and economic outcomes showed similar trends.

CONCLUSIONS

Among the Medicare population undergoing coronary revascularization, the introduction of drug-eluting stents was associated with increased use of initial percutaneous coronary intervention and reduced bypass surgery along with improved clinical outcomes over approximately 2 years of follow-up. Although total cardiovascular-related costs per revascularized patient decreased over this time period, total cost to the Medicare system still increased owing to greater overall use of revascularization procedures.

Disparity in drug-eluting stent utilization by insurance type

BACKGROUND

Because of the expense of drug-eluting stents (DES) and associated adjuvant therapy, nonclinical, socioeconomic factors may be associated with DES use in clinical practice.

METHODS

Data on 112,588 patients from the National Cardiovascular Data CathPCI Registry (NCDR) between 2004 and 2005 with "on-label" indications for DES were analyzed. Insurance status was categorized as No Insurance, Governmental, and Private Insurance. Hierarchical multivariable logistic regression analyses were used to evaluate the association between insurance status and DES use, after adjusting for patient and procedural characteristics.

RESULTS

Drug-eluting stent use was >96% during the study period, with utilization significantly associated with insurance status. Compared with patients with Private Insurance, patients with No Insurance (odds ratio 0.44, 95% confidence interval 0.37-0.53) and Government Insurance (odds ratio 0.73, 95% confidence interval 0.67-0.80) were significantly less likely to receive a DES than a bare metal stent. Repeat analysis of patients <65 years of age demonstrated virtually identical results.

CONCLUSIONS

Despite the high penetration of DES, significant associations between insurance status and DES utilization were identified. This indicates that disparities in health care based on socioeconomic factors extend to DES utilization and highlights the need to address such disparities as novel therapies emerge.

Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction

Background— Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction with bare metal stents (BMS) is well established, while randomized trials suggest equivalent safety and reduced repeat revascularization with drug-eluting stents (DES) in this setting. However, long-term data on DES in PPCI is lacking, especially in those ineligible for inclusion in randomized trials. Our aim was to investigate the long-term outcomes of unselected patients undergoing PPCI with BMS and DES.

Methods and Results— We analyzed all patients (n=1738) undergoing PPCI for a de novo lesion in our institution from 2000 to 2005. Patients from 3 sequential consecutive cohorts of BMS (n=531), sirolimus-eluting (SES, n=185) or paclitaxel-eluting stents (PES, n=1022) were included. The median duration of follow-up was 1185 days (interquartile range, 746 to 1675). There were no differences in all-cause mortality or repeat revascularization between DES and BMS, although there was a nonsignificant trend toward improved survival with SES compared with both BMS (propensity score-adjusted hazard ratio, 0.63; [95%CI, 0.33 to 1.18]) and PES (hazard ratio, 0.71; [95% CI, 0.40 to 1.26]). SES were associated with lower rates of the composite end point of all-cause death, nonfatal myocardial infarction, or target vessel revascularization (hazard ratio, 0.62; 95%CI, 0.40 to 0.96) when compared with PES. Very late stent thrombosis only occurred in the DES groups.

Conclusions— Although DES are not associated with an increase in adverse events compared with BMS when used for PPCI, neither DES reduced repeat revascularizations. Appropriately powered randomized trials with hard clinical end points and an “all-comer” design are required to further assess the benefit of DES in PPCI.

Health care costs, long-term survival, and quality of life following intensive care unit admission after cardiac arrest

Introduction

The purpose of this study was to investigate the costs and health status outcomes of intensive care unit (ICU) admission in patients who present after sudden cardiac arrest with in-hospital or out-of-hospital cardiopulmonary resuscitation.

Methods

Five-year survival, health-related quality of life (Medical Outcome Survey Short Form-36 questionnaire, SF-36), ICU costs, hospital costs and post-hospital health care costs per survivor, costs per life year gained, and costs per quality-adjusted life year gained of patients admitted to a single ICU were assessed.

Results

One hundred ten of 354 patients (31%) were alive 5 years after hospital discharge. The mean health status index of 5-year survivors was 0.77 (95% confidence interval 0.70 to 0.85). Women rated their health-related quality of life significantly better than men did (0.87 versus 0.74; P < 0.05). Costs per hospital discharge survivor were 49,952 €. Including the costs of post-hospital discharge health care incurred during their remaining life span, the total costs per life year gained were 10,107 €. Considering 5-year survivors only, the costs per life year gained were calculated as 9,816 € or 14,487 € per quality-adjusted life year gained. Including seven patients with severe neurological sequelae, costs per life year gained in 5-year survivors increased by 18% to 11,566 €.

Conclusion

Patients who leave the hospital following cardiac arrest without severe neurological disabilities may expect a reasonable quality of life compared with age- and gender-matched controls. Quality-adjusted costs for this patient group appear to be within ranges considered reasonable for other groups of patients.