Optimum percutaneous transluminal coronary angioplasty compared with routine stent strategy trial (OPUS-1): a randomised trial

Drug-coated balloon angioplasty with rescue stenting versus intended stenting for the treatment of patients with de novo coronary artery lesions (REC-CAGEFREE I): an open-label, randomised, non-inferiority trial

BACKGROUND

The long-term impact of drug-coated balloon (DCB) angioplasty for the treatment of patients with de novo coronary artery lesions remains uncertain. We aimed to assess the non-inferiority of DCB angioplasty with rescue stenting to intended drug-eluting stent (DES) deployment for patients with de novo, non-complex coronary artery lesions.

METHODS

REC-CAGEFREE I was an open-label, randomised, non-inferiority trial conducted at 43 sites in China. After successful lesion pre-dilatation, patients aged 18 years or older with de novo, non-complex coronary artery disease (irrespective of target vessel diameter) and an indication for percutaneous coronary intervention were randomly assigned (1:1), via a web-based centralised system with block randomisation (block size of two, four, or six) and stratified by site, to paclitaxel-coated balloon angioplasty with the option of rescue stenting due to an unsatisfactory result (DCB group) or intended deployment of second-generation thin-strut sirolimus-eluting stents (DES group). The primary outcome was the device-oriented composite endpoint (DoCE; including cardiovascular death, target vessel myocardial infarction, and clinically and physiologically indicated target lesion revascularisation) assessed at 24 months in the intention-to-treat (ITT) population (ie, all participants randomly assigned to treatment). Non-inferiority was established if the upper limit of the one-sided 95% CI for the absolute risk difference was smaller than 2·68%. Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT04561739. It is closed to accrual and extended follow-up is ongoing.

FINDINGS

Between Feb 5, 2021, and May 1, 2022, 2272 patients were randomly assigned to the DCB group (1133 [50%]) or the DES group (1139 [50%]). Median age at the time of randomisation was 62 years (IQR 54-69), 1574 (69·3%) of 2272 were male, 698 (30·7%) were female, and all patients were of Chinese ethnicity. 106 (9·4%) of 1133 patients in the DCB group received rescue DES after unsatisfactory DCB angioplasty. As of data cutoff (May 1, 2024), median follow-up was 734 days (IQR 731-739). At 24 months, the DoCE occurred in 72 (6·4%) of 1133 patients in the DCB group and 38 (3·4%) of 1139 in the DES group, with a risk difference of 3·04% in the cumulative event rate (upper boundary of the one-sided 95% CI 4·52; pnon-inferiority=0·65; two-sided 95% CI 1·27-4·81; p=0·0008); the criterion for non-inferiority was not met. During intervention, no acute vessel closures occurred in the DCB group and one (0·1%) of 1139 patients in the DES group had acute vessel closure. Periprocedural myocardial infarction occurred in ten (0·9%) of 1133 patients in the DCB group and nine (0·8%) in the DES group.

INTERPRETATION

In patients with de novo, non-complex coronary artery disease, irrespective of vessel diameter, a strategy of DCB angioplasty with rescue stenting did not achieve non-inferiority compared with the intended DES implantation in terms of the DoCE at 2 years, which indicates that DES should remain the preferred treatment for this patient population.

FUNDING

Xijing Hospital and Shenqi Medical.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Drug-coated balloon angioplasty with provisional stenting versus primary stenting for the treatment of de novo coronary artery lesions: REC-CAGEFREE I trial rationale and design

BACKGROUND

Percutaneous coronary intervention (PCI) with primary stenting, which stands for stent implantation regardless of obtaining satisfactory results with balloon angioplasty, has superseded conventional plain old balloon angioplasty with provisional stenting. With drug-coated balloon (DCB), primary DCB angioplasty with provisional stenting has shown non-inferiority to primary stenting for de novo coronary small vessel disease. However, the long-term efficacy and safety of such a strategy to the primary stenting on clinical endpoints in de novo lesions without vessel diameter restrictions remain uncertain.

STUDY DESIGN

The REC-CAGEFREE I is an investigator-initiated, multicenter, randomized, open-label trial aimed to enroll 2270 patients with acute or chronic coronary syndrome from 43 interventional cardiology centers in China to evaluate the non-inferiority of primary paclitaxel-coated balloons angioplasty to primary stenting for the treatment of de novo, non-complex lesions without vessel diameter restrictions. Patients who fulfill all the inclusion and exclusion criteria and have achieved a successful lesion pre-dilatation will be randomly assigned to the two arms in a 1:1 ratio. Protocol-guided DCB angioplasty and bailout stenting after unsatisfactory angioplasty are mandatory in the primary DCB angioplasty group. The second-generation sirolimus-eluting stent will be used as a bailout stent in the primary DCB angioplasty group and the treatment device in the primary stenting group. The primary endpoint is the incidence of Device-oriented Composite Endpoint (DoCE) within 24 months after randomization, including cardiac death, target vessel myocardial infarction, and clinically and physiologically indicated target lesion revascularization.

DISCUSSION

The ongoing REC-CAGEFREE I trial is the first randomized trial with a clinical endpoint to assess the efficacy and safety of primary DCB angioplasty for the treatment of de novo, non-complex lesions without vessel diameter restrictions. If non-inferiority is shown, PCI with primary DCB angioplasty could be an alternative treatment option to primary stenting.

TRIAL REGISTRATION

Registered on clinicaltrial.gov (NCT04561739).

Up to 15-Year Survival of Men and Women after Percutaneous Coronary Intervention Paid by the Brazilian Public Healthcare System in the State of Rio de Janeiro, 1999-2010

Background

Percutaneous coronary intervention (PCI) is the most frequently used invasive therapy for ischemic heart disease (IHD). Studies able to provide information about PCI's effectiveness should be conducted in a population of real-world patients.

Objectives

To assess the survival rate of IHD patients treated with PCI in the state of Rio de Janeiro (RJ).

Methods

Administrative (1999-2010) and death (1999-2014) databases of dwellers aged ≥ 20 years old in the state of RJ submitted to one single PCI paid by the Brazilian public healthcare system (SUS) between 1999 and 2010 were linked. Patients were grouped as follows: 20-49 years old, 50-69 years old and ≥ 70 years old, and PCI in primary PCI, with stent and without stent placement (bare metal stent). Survival probabilities in 30 days, one year and 15 years were estimated by using the Kaplan-Meier method. Cox hazards regression models were used to compare risks among sex, age groups and types of PCI. Test results with a p-value < 0.05 were deemed statistically significant.

Results

Data of 19,263 patients (61 ± 11 years old, 63.6% men) were analyzed. Survival rates of men vs. women in 30 days, one year and 15 years were: 97.3% (97.0-97.6%) vs. 97.1% (96.6-97.4%), 93.6% (93.2-94.1%) vs. 93.4% (92.8-94.0%), and 55.7% (54.0-57.4%) vs. 58.1% (55.8-60.3%), respectively. The oldest age group was associated with lower survival rates in all periods. PCI with stent placement had higher survival rates than those without stent placement during a two-year follow-up. After that, both procedures had similar survival rates (HR 0.91, 95% CI 0.82-1.00).

Conclusions

In a population of real-world patients, women had a higher survival rate than men within 15 years after PCI. Moreover, using a bare-metal stent failed to improve survival rates after a two-year follow-up compared to simple balloon angioplasty.

Surgical versus percutaneous revascularization in patients with multivessel coronary artery disease

New-generation stents have been continually developed in order to improve the safety and efficacy of percutaneous coronary intervention (PCI). Several randomized clinical trials have been conducted over the last two decades to compare the outcomes of PCI with coronary artery bypass grafting (CABG), which has been the time-tested treatment of multivessel coronary artery disease. The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial is one of the most recent and largest randomized controlled trials comparing PCI using the paclitaxel-eluting first-generation stent with CABG and was uniquely formulated to represent "real world" daily practice. The final 5-year main results of this trial and its various prespecified subgroups have been published in the past year. These results will form the basis of the new guidelines that will be published in the near future. This review is a compilation of the results of the SYNTAX trial and comparisons with other contemporary trials, meta-analyses, and retrospective studies of large registries and how these results help cardiac surgeons and cardiologists in judicious decision-making for their patients with multivessel coronary artery disease requiring revascularization.

Drug-eluting stents: from evidence to policy

Drug-eluting stents are a major breakthrough in cardiology, with the Cypher (Cordis Corporation) and Taxus (Boston Scientific) stents preventing 60-70% of repeat coronary revascularizations, compared with bare metal stents. Both evidence- and risk-based application of drug-eluting stents is expected to create relevant financial and equity problems to most public hospitals, as the cost of drug-eluting stents is over 1000 higher than traditional stents. In the perspective of third-party payers, drug-eluting stents are cost-effective revascularization strategies for a large portion of patients actually undergoing stenting. However, adequate guidelines and reimbursement strategies are still awaited in several countries.

Cost-effectiveness of drug-eluting stents versus bare metal stents in clinical practice

BACKGROUND

Drug-eluting stents (DES) reduce the need for repeat target revascularization (TVR) compared with bare metal stents (BMS) but are more costly. The objective was to evaluate the cost-effectiveness of DES versus BMS.

METHODS AND RESULTS

We evaluated clinical outcomes and costs of care over 3 years in 1147 undergoing BMS before the availability of DES and 1247 DES patients at Wake Forest University Baptist Medical Center from 2002 to 2005. Costs for index stenting, TVR, and clopidogrel use were assessed. The 2 groups were well matched for baseline characteristics. Index stenting costs were $1846 higher per patient for DES versus BMS ($1737 more to $1950 more). At 3 years, absolute TVR rates were 15.2 per 100 DES patients and 24.1 per 100 BMS patients, and as a result, cumulative TVR-related costs were $2065 less per patient for DES versus BMS ($3001 less to $1134 less). Including the cost of clopidogrel, the incremental cost-effectiveness ratio per TVR avoided with DES was $4731 through 1 year, $4703 through 2 years, and $6379 through 3 years.

CONCLUSIONS

At 3 years, the higher index cost of DES versus BMS was completely offset by lower TVR-related costs. However, because of extended clopidogrel use for DES, the incremental cost-effectiveness ratio per TVR avoided ranged from $4703 to $6379 over 3 years. These unadjusted observational findings provide support for the continued use of DES in routine practice but highlight the important impact of prolonged dual antiplatelet use on the cost-effectiveness of this technology.

Long-term outcome after drug-eluting stent implantation in comparison with bare metal stents: a single centre experience

BACKGROUND

The aim of our study was to evaluate the effect of drug-eluting stents (DES) compared with bare-metal stents (BMS) on all-cause mortality and target vessel revascularization (TVR) in a "real-world" clinical setting.

METHODS AND RESULTS

One thousand four hundred and ninety consecutive patients, who underwent PCI, were included in a prospective registry from January 2003 until December 2006. Patients were divided retrospectively into two groups: those who received a DES and those who received a BMS. The primary combined endpoint all-cause mortality or TVR and the individual endpoints death and TVR were evaluated during a mean follow-up period of 24.56 ± 12.5 months (range 6-52 months). In total 1,033 patients (69.3%) received BMS, while 457 patients (30.7%) received DES. With respect to clinical characteristics, significant differences between groups were found for age, hyperlipidemia, diabetes mellitus, heart failure, previous cerebral insult and presence of acute coronary syndrome (ACS) during intervention. Propensity score analysis was performed in attempt to eliminate this selection bias. With respect to the combined endpoint all-cause death or TVR, 12.9% of patients with DES and 21.3% with BMS (p = 0.015) had an event during the follow-up. 12.3% of patients with BMS but only 5.7% with DES died during the follow-up (p = 0.025). Thirty-three patients (7.2%) of the DES group and 99 patients (9.6%) of the BMS group (p = 0.1) needed TVR.

CONCLUSION

Our results obtained in a "real-world" clinical setting exhibit a clinical long-term benefit for DES compared with BMS and underline the safety and efficacy of DES over BMS.

The role of endothelial cells and their progenitors in intimal hyperplasia

Intimal hyperplasia leading to restenosis is the major process that limits the success of cardiovascular intervention. The emergence of vascular progenitor cells and, in particular, endothelial progenitor cells has led to great interest in their potential therapeutic value in preventing intimal hyperplasia. We review the mechanism of intimal hyperplasia and highlight the important attenuating role played by a functional endothelium. The role of endothelial progenitor cells in maintaining endothelial function is reviewed and we describe how reduced progenitor cell number and function and reduced endothelial function lead to an increased risk of intimal hyperplasia. We review other potential sources of endothelial cells, including monocytes, mesenchymal stem cells and tissue resident stem cells. Endothelial progenitor cells have been used in clinical trials to reduce the risk of restenosis with varied success. Progenitor cells have huge therapeutic potential to prevent intimal hyperplasia but a more detailed understanding of vascular progenitor cell biology is necessary before further clinical trials are commenced.

Safety and efficacy update on first-generation drug-eluting stents

Accumulating data on the safety and efficacy of first-generation drug-eluting stents (DES) show a favorable risk/benefit profile compared with bare-metal stents (BMS). A recently reported collaborative network meta-analysis including >18,000 patients in 38 randomized trials along with other recent meta-analyses indicate that the use of DES versus BMS is associated with a 50%-70% reduction in the need for repeat revascularization and no difference in the rates of overall stent thrombosis, overall mortality, cardiac mortality, or death or myocardial infarction over 4 years of follow-up. Furthermore, the most recent data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) indicate no difference in mortality between DES and BMS use. The collaborative network meta-analysis and other analyses suggest that late stent thrombosis is a distinct but infrequent phenomenon complicating the use of DES; the risk posed by late thrombosis appears to be offset by a reduced need for repeat revascularizations and thus, a reduced risk of adverse outcomes associated with such interventions.

Are "treatment" bare metal stents superior to "control" bare metal stents? A meta-analytic approach

BACKGROUND

It has been suggested that the benefits of drug-eluting stents compared to bare metal stents (BMS) have been overestimated in part because target lesion/vessel revascularization (TLR/TVR) rates in the BMS control group of these trials were spuriously high.

METHODS

We used meta-analytic techniques to systematically compare clinical event rates among patients treated with BMS in trials where BMS were the experimental (BMS(experimental)) rather than the control (BMS(control)) intervention. MEDLINE searches were performed to identify eligible randomized trials comparing either drug-eluting stents with BMS(control) or BMS(experimental) with balloon angioplasty in patients with nonacute coronary artery disease. Trial characteristics and 6- to 12-month rates for death, myocardial infarction, TLR/TVR, and major adverse cardiac events were extracted and assessed.

RESULTS

Eligible trials yielded 50 BMS cohorts: 19 in the BMS(control) group (4046 patients) and 31 in the BMS(experimental) group (5068 patients). Summary death and infarction rates did not differ between groups. The summary TLR/TVR rates were 16.2% (95% CI 13.5-19.3) versus 13.8% (95% CI 12.0-15.7) in BMS(control) versus BMS(experimental) groups, respectively (P = .15). Among 39 BMS cohorts with < or = 250 patients, TLR/TVR rates were significantly higher in BMS(control) versus BMS(experimental) groups (18.9% [95% CI 16.0-22.2] vs 13.7% [95% CI 11.5-16.3], P = .01). There were no between-group differences among larger BMS cohorts (P = .98).

CONCLUSIONS

Although overall clinical event rates did not differ in the BMS(control) and the BMS(experimental) groups, a higher rate of TVR/TLR was seen in the BMS(control) group among smaller trials.

Cost-effectiveness of sirolimus-eluting stents compared with vascular brachytherapy for the treatment of in-stent restenosis

BACKGROUND

Sirolimus-eluting stents (SESs) were recently shown to be superior to vascular brachytherapy for the treatment of restenosis within a bare metal stent. No economic comparison of these alternative strategies has yet been reported.

METHODS

We conducted a prospective health economic study involving all patients randomized to SES (n = 259) or brachytherapy (n = 125) in the SISR trial. Procedural, hospital, and outpatient costs, as well as physician fees, were estimated through 12 months based on measured resource use and itemized hospital bills. Cost-effectiveness was assessed in terms of the cost per repeat revascularization avoided, cost per major adverse cardiac event avoided, and cost per event-free patient.

RESULTS

Although initial device costs were approximately $1100/patient higher in the SES group, this was offset by higher physician fees associated with brachytherapy, such that initial hospitalization costs were similar for the 2 groups. Because SES significantly reduced repeat revascularization procedures and major adverse cardiac event compared with brachytherapy during follow-up, cumulative 12-month costs were significantly lower in the SES group ($16,482 vs $19,435, mean difference -$2953, 95% CI -$5470 to -$792). Sirolimus-eluting stenting was thus both more effective and less expensive than brachytherapy, as confirmed in >98% of bootstrap replications for each of the cost-effectiveness outcomes.

CONCLUSIONS

Compared with vascular brachytherapy, SES is an economically dominant strategy for the treatment of in-stent restenosis.

The pathophysiology and burden of restenosis

The introduction of percutaneous transluminal coronary angioplasty (PTCA) revolutionized the surgical treatment of coronary artery disease. However, despite increased surgical experience and technical breakthroughs, restenosis occurs in 30%-50% of patients undergoing simple balloon angioplasty and in 10%-30% of patients who receive an intravascular stent. Animal and human data indicate that restenosis is a response to injury incurred during PTCA. The need for reintervention in a high percentage of patients due to restenosis remains an important limitation to the long-term success of PTCA. Stenting reduces initial elastic recoil and limits negative arterial remodeling; however, bare-metal stents may promote intimal hyperplasia by eliciting an immune and proliferative response. Consistent with these data, clinical studies suggest that drug-eluting stents, coated with anti-inflammatory or antiproliferative agents, reduce the risk for restenosis. Stenting represents a considerable cost burden. Treatment strategy should focus on selective use of expensive drug-eluting stents in populations where they have been found to be more clinically effective than bare-metal stents--patients who are at high risk for restenosis or who develop restenosis with bare-metal stents. Recent studies suggest that the pharmacologic management of restenosis is now feasible. Together, the judicious use of stents and oral pharmacotherapy promise to reduce the risk for restenosis, even among high-risk patients.

The costs and quality-of-life outcomes of drug-eluting coronary stents: a systematic review

OBJECTIVES

While the efficacy of drug-eluting coronary stents (DES) has been demonstrated by several clinical trials, the impact of DES on health-care costs and recipient quality of life (QOL) is controversial. We performed a systematic review of the published literature on DES costs and the QOL effects of restenosis and target vessel revascularization (TVR).

METHODS

Among 536 potential articles initially identified by a broad search, 12 publications ultimately met inclusion criteria. Data were independently abstracted, evaluated for quality and relevance, and summarized by two reviewers. Excessive heterogeneity among these studies prevented formal meta-analysis, thus a narrative synthesis of the literature was performed.

RESULTS

In four economic studies, DES recipients had 1,600 dollars-3,200 dollars higher up-front costs than recipients of bare metal stents, but the differences in total costs after 1 year were less pronounced (200 dollars-1,200 dollars), and estimates of the average cost of an avoided revascularization ranged widely (1,800 dollars-36,900 dollars). All eight QOL studies indicated that restenosis was associated with lower QOL, but only two studies quantified this in terms of quality-adjusted life years (QALYs), with estimates ranging from 0.06 to 0.08. An additional study estimated that the median willingness to pay to prevent restenosis was 2,400 dollars-3,600 dollars.

CONCLUSIONS

There is a lack of convergence in the literature on the cost of DES in avoiding TVR. There is more agreement that the average QALY benefit of an avoided revascularization is 0.04-0.08. This implies that use of DES in patients where the average cost per avoided revascularization exceeds 8,000 dollars may be less likely to be cost-effective.

Anxiety enhances the detrimental effect of depressive symptoms on health status following percutaneous coronary intervention

OBJECTIVE

We examined whether anxiety has incremental value to depressive symptoms in predicting health status in patients undergoing percutaneous coronary intervention (PCI) treated in the drug-eluting stent era.

METHODS

A series of consecutive patients (n=692) undergoing PCI as part of the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital registry completed the Hospital Anxiety and Depression Scale at 6 months and the Short-Form Health Survey (SF-36) at 6 and 12 months post-PCI.

RESULTS

Of 692 patients, 471 (68.1%) had no symptoms of anxiety nor depression, 62 (9.0%) had anxiety only, 59 (8.5%) had depressive symptoms only, and 100 (14.5%) had co-occurring symptoms. There was an overall significant improvement in health status between 6 and 12 months post-PCI (P<.001); the interaction effect for time by psychological symptoms was also significant (P=.003). Generally, patients with co-occurring symptoms reported significantly poorer health status compared with the other three groups (Ps <.001). Patients with co-occurring symptomatology were also at greater risk of impaired health status on six of the eight subdomains of the SF-36 compared with the other three symptom groups, adjusting for baseline characteristics and health status at 6 months.

CONCLUSION

Patients with co-occurring symptoms of anxiety and depression reported poorer health status compared with anxious or depressed-only patients and no-symptom patients, showing that anxiety has incremental value to depressive symptoms in identifying PCI patients at risk for impaired health status treated in the drug-eluting stent era.

Cost effectiveness of paclitaxel-eluting stents for patients undergoing percutaneous coronary revascularization: results from the TAXUS-IV Trial

OBJECTIVES

This study sought to compare aggregate medical care costs for patients undergoing percutaneous coronary intervention with paclitaxel-eluting stents (PES) and bare-metal stents (BMS) and to formally evaluate the incremental cost effectiveness of PES for patients undergoing single-vessel percutaneous coronary intervention.

BACKGROUND

Although the cost effectiveness of SES has been studied in both clinical trials and decision-analytic models, few data exist on the cost effectiveness of alternative drug-eluting stent (DES) designs. In addition, no clinical trials have specifically examined the cost effectiveness of DES among patients managed without mandatory angiographic follow-up.

METHODS

We performed a prospective economic evaluation among 1,314 patients undergoing percutaneous coronary revascularization randomized to either PES (N = 662) or BMS (N = 652) in the TAXUS-IV trial. Clinical outcomes, resource use, and costs (from a societal perspective) were assessed prospectively for all patients over a 1-year follow-up period. Cost effectiveness was defined as the incremental cost per target vessel revascularization (TVR) event avoided and was analyzed separately among cohorts assigned to mandatory angiographic follow-up (n = 732) or clinical follow-up alone (n = 582).

RESULTS

The PES reduced TVR by 12.2 events per 100 patients treated, resulting in a 1-year cost difference of 572 dollars per patient with incremental cost-effectiveness ratios of 4,678 dollars per TVR avoided and 47,798 dollars/quality-adjusted life year (QALY) gained. Among patients assigned to clinical follow-up alone, the net 1-year cost difference was 97 dollars per patient with cost-effectiveness ratios of 760 dollars per TVR event avoided and $5,105/QALY gained.

CONCLUSIONS

In the TAXUS-IV trial, treatment with PES led to substantial reductions in the need for repeat revascularization while increasing 1-year costs only modestly. The cost-effectiveness ratio for PES in the study population compares reasonably with that for other treatments that reduce coronary restenosis, including alternative drug-eluting stent platforms.

Comparison of long-term (seven year) outcomes among patients undergoing percutaneous coronary revascularization with versus without stenting

Coronary stents have markedly improved the short- and intermediate-term safety and efficacy of percutaneous coronary intervention by improving acute gains in luminal dimensions, decreasing abrupt vessel occlusion, and decreasing restenosis, yet the long-term benefit of coronary stenting remains uncertain. We examined long-term clinical outcomes of death, myocardial infarction, and repeat target vessel revascularization (TVR) among patients enrolled in the Duke Database for Cardiovascular Disease who underwent revascularization with percutaneous transluminal coronary angioplasty alone or stent placement from 1990 to 2002. Among 6,956 patients who underwent percutaneous revascularization, propensity modeling was applied to identify 1,288 matched patients with a similar likelihood to receive coronary stents according to clinical, angiographic, and demographic characteristics. Significant (p <0.05) predictors of stent placement included multivessel disease, diabetes, hypertension, recent myocardial infarction, decreased ejection fraction, and year of study entry. At a median follow-up of 7 years, although treatment with coronary stenting was associated with a significant and sustained decrease in repeat TVR (18.0% vs 28.1%, p = 0.0002) and the occurrence of death, myocardial infarction or TVR (39.2% vs 45.8%, p = 0.004), long-term survival did not significantly differ between treatment groups (19.9% vs 20.5%, p = 0.72). Outcomes of death and myocardial infarction did not significantly differ between patients who did and did not undergo repeat TVR. In conclusion, compared with angioplasty alone, revascularization with coronary stents provides a significant early and sustained decrease in the need for repeat revascularization, but stents do not influence long-term survival.

Decision models for assessing the cost effectiveness of drug-eluting stents

Percutaneous coronary intervention is an increasingly common treatment for many people with coronary disease. Randomised trials using antiproliferative, drug-eluting stents (DES) have shown important reductions in the need for repeat procedures after initial percutaneous coronary intervention. These trials indicate that the growing use of DES has the potential to create major clinical benefits for patients; however, in actual practice, the associated costs may cause financial crises for hospital systems. This paper reviews previously published DES economic decision models from both societal and hospital perspectives. From a social perspective, additional spending for new technologies may be acceptable if these technologies convincingly improve the lives of patients. The models reviewed suggest that DES incurs large costs to both society and hospitals, and currently offers uncertain clinical benefits. More research is recommended to identify high-risk patients who stand to gain significant health benefits from this therapy.

Dutch Iliac Stent Trial: Long-term Results in Patients Randomized for Primary or Selective Stent Placement

PURPOSE

To determine long-term results of the prospective Dutch Iliac Stent Trial.

MATERIALS AND METHODS

The study protocol was approved by local institutional review boards. All patients gave written informed consent. Two hundred seventy-nine patients (201 men, 78 women; mean age, 58 years) with iliac artery disease were randomly assigned to undergo primary stent placement (143 patients) or percutaneous transluminal angioplasty (PTA) with selective stent placement in cases in which the residual mean pressure gradient was greater than 10 mm Hg across the treated site (136 patients). Before and at 3, 12, and 24 months and 5-8 years after treatment, all patients underwent assessment, which included duplex ultrasonography (US), ankle-brachial index (ABI) measurement, Fontaine classification of symptoms, and completion of the Rand 36-Item Health survey for quality-of-life assessment. Treatment was considered successful for symptoms if symptoms increased at least one Fontaine grade, for ABI if ABI increased more than 0.10, for patency if peak systolic velocity ratio at duplex US was less than 2.5, and for quality of life if the RAND 36-Item Health Survey score increased more than 15 points. Effects of both treatments on symptoms, quality of life, patency, and ABI were compared by using survival analyses.

RESULTS

Patients who underwent PTA and selective stent placement had better improvement of symptoms (hazard ratio [HR], 0.8; 95% confidence limits [CLs]: 0.6, 1.0) than did patients treated with primary stent placement, whereas ABI (HR, 0.9; 95% CLs: 0.7, 1.3), iliac patency (HR, 1.3; 95% CLs: 0.8, 2.1), and score for quality of life for nine survey dimensions did not support a difference between treatment groups.

CONCLUSION

Patients treated with PTA and selective stent placement in the iliac artery had a better outcome for symptomatic success compared with patients treated with primary stent placement, whereas data about iliac patency, ABI, and quality of life did not support a difference between groups.

Provisional stenting for multivessel PCI

BACKGROUND

Bare stents reduce acute complications and repeat revascularization following percutaneous coronary intervention (PCI), but are costly and may lead to in-stent restenosis. It remains unclear whether stents should be universally implanted or whether provisional stenting mainly to suboptimal balloon dilatation results is an acceptable approach for multivessel PCI.

OBJECTIVE

To compare the long-term clinical restenosis and target lesion revascularization (TLR) of stented and non-stented coronary artery lesions in patients who had multivessel PCI.

METHODS

We performed retrospective analysis of matched data from 129 consecutive patients who underwent multivessel PCI (at least optimal balloon angioplasty to one coronary artery segment and balloon angioplasty plus stenting to another coronary artery in the same patient, all lesions are de novo native coronary artery lesions with vessel diameter >/=2.5 mm). The study endpoint was restenosis and repeat revascularization at one-year follow-up.

RESULTS

Baseline characteristics were similar in both groups. Low in-hospital MACE (3.1%). Acute myocardial infarction, emergency revascularization via either PCI or CABG was detected and angiographic success was achieved in 99.3% of lesions in both groups. The rate of clinically driven angiographic restenosis and TLR at one-year (follow-up 100%) was similar (17.1% versus 18.6%, P=0.871, and 13.9% versus 16.3%, P=0.728, for optimal balloon angioplasty versus provisional stenting.

CONCLUSIONS

The main findings from this study are that long-term angiographic restenosis and TLR was comparable for optimal balloon angioplasty and provisional stenting, suggesting that provisional stenting is an acceptable approach for multivessel PCI.

Economic evaluation of sirolimus-eluting stents

BACKGROUND

Sirolimus-eluting stents have recently been shown to reduce the risk of restenosis among patients who undergo percutaneous coronary intervention (PCI). Given that sirolimus-eluting stents cost about 4 times as much as conventional stents, and considering the volume of PCI procedures, the decision to use sirolimus-eluting stents has large economic implications.

METHODS

We performed an economic evaluation comparing treatment with sirolimus-eluting and conventional stents in patients undergoing PCI and in subgroups based on age and diabetes mellitus status. The probabilities of transition between clinical states and estimates of resource use and health-related quality of life were derived from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. Information on effectiveness was based on a meta-analysis of randomized controlled clinical trials (RCTs) comparing sirolimus-eluting and conventional stents.

RESULTS

Cost per quality-adjusted life year (QALY) gained in the baseline analysis was Can58,721 dollars. Sirolimus-eluting stents were more cost-effective in patients with diabetes and in those over 75 years of age, the costs per QALY gained being 44,135 dollars and 40,129 dollars, respectively. The results were sensitive to plausible variations in the cost of stents, the estimate of the effectiveness of sirolimus-eluting stents and the assumption that sirolimus-eluting stents would prevent the need for cardiac catheterizations in the subsequent year when no revascularization procedure was performed to treat restenosis.

INTERPRETATION

The use of sirolimus-eluting stents is associated with a cost per QALY that is similar to or higher than that of other accepted medical forms of therapy and is associated with a significant incremental cost. Sirolimus-eluting stents are more economically attractive for patients who are at higher risk of restenosis or at a high risk of death if a second revascularization procedure were to be required.

Primary stenting versus primary balloon angioplasty for treating acute myocardial infarction

BACKGROUND

Balloon angioplasty following myocardial infarction (MI) reduces death, non-fatal MI and stroke compared to thrombolytic reperfusion. However up to 50% of patients experience restenosis and 3% to 5% recurrent myocardial infarction. Therefore, primary stenting may offer additional benefits compared to balloon angioplasty in patients with acute myocardial infarction.

OBJECTIVES

To examine whether primary stenting compared to primary balloon angioplasty reduces clinical outcomes in patients with acute myocardial infarction.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Pascal, Index medicus and The Cochrane Controlled Trials Register (The Cochrane Library) from 1979 to March 2002.

SELECTION CRITERIA

Randomised controlled trials of primary stenting or balloon angioplasty prior to the invasive procedure; intervention in native coronary arteries within 24 hours after onset of symptoms of myocardial infarction; report of death or reinfarction; and follow-up of at least 1 month. Trials were excluded when randomisation occurred after an invasive procedure and if they exclusively included patients with cardiogenic shock.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected and extracted data from identified trials. Outcomes included mortality, reinfarction, coronary artery bypass grafting, target vessel revascularization, need for vascular repair or blood transfusion. Peto odds ratios were calculated. To explore the stability of the overall treatment effect various sensitivity analyses were performed.

MAIN RESULTS

We included nine trials of 4433 participants. Odds ratios for mortality after stenting compared to balloon angioplasty at 30 days, 6 and 12 months were 1.16 (95% CI 0.78 to 1.73), 1.27 (95% CI 0.89 to 1.83), and 1.06 (95% CI 0.77 to 1.45). At 30 days, 6 and 12 months odds ratios for reinfarction after stenting compared to balloon angioplasty were 0.52 (95% CI 0.31 to 0.87), 0.67 (95% CI 0.45 to 1.00), and 0.67 (95% CI 0.45-0.98) and odds ratio for target vessel revascularization after stenting compared to balloon angioplasty were 0.45 (95%CI 0.34 to 0.60), 0.42 (95% CI 0.35 to 0.51), and 0.47 (95% CI 0.38 to 0.57). The odds ratio for post-interventional bleeding complications after stenting compared to balloon angioplasty was 1.34 (95% CI 0.95 to 1.88; test of heterogeneity p > 0.1).

AUTHORS' CONCLUSIONS

There is no evidence to suggest that primary stenting reduces mortality when compared to balloon angioplasty. Stenting seems to be associated with a reduced risk of reinfarction and target vessel revascularization, but potential confounding due to unbalanced post-interventional antithrombotic/anticoagulant therapies can not be ruled out on basis of this review.

Dollars and Stents: The Economics of Drug-Eluting Stents

By averting restenoses, drug-eluting stents (DES) reduce the need for repeat revascularization procedures and improve quality of life. Large, randomized clinical trials including the Sirolimus-Eluting Balloon Expandable Stent in Treatment of Patients With De Novo Native Coronary Artery Lesions (SIRIUS) suggest that DES may be cost-effective to the Medicare system over time. However, the high cost of DES and the loss of revenues from revascularization procedures coupled with inadequate Medicare reimbursement are likely to have adverse effects on hospitals, making it hard to meet their bottom line. Key contributors to this problem include the unequal distribution of Medicare reimbursement based on diagnosis-related groups or diagnosis-related group calculations and the lack of price competition for DES. The economic burden of restenoses, the efficacy of DES in averting restenoses, the cost-effectiveness of DES, and the interaction of Medicare, DES manufacturers, and hospitals are reviewed. Using specific cost-containment strategies, hospitals can better maneuver the financial barriers to optimize DES utilization.

Real-world bare metal stenting: identification of patients at low or very low risk of 9-month coronary revascularization

The high cost of drug-eluting stents (DESs) has made identification of patients who are at low risk for subsequent revascularization after treatment with bare metal stents (BMSs) highly desirable. Previous reports from randomized trials suffer from biases induced by restricted entry criteria and protocol-mandated angiographic follow-up. Between 1994 and 2001, 5,239 consecutive BMS patients, excluding those with coil stents, technical failure, brachytherapy, staged procedure, or stent thrombosis within 30 days, were prospectively identified from a large single-center tertiary-referral-center prospective registry for long-term follow-up. We sought to identify characteristics of patients with very low (< or = 4%) or low (4-10%) likelihood of coronary revascularization 9 months after BMS. Nine-month clinical follow-up was obtained in 98.2% of patients. Coronary revascularization was required in 13.4% and did not differ significantly by stent type. On the basis of multivariate analysis identifying 11 independent correlates and previous reports, 20 potential low-risk patient and lesion groups (228 +/- 356 patients/groups) were identified (e.g, patients with all of the following: native vessel, de novo, reference diameter > or = 3.5 mm, lesion length < 5 mm, no diabetes, not ostial in location). Actual and model-based outcomes were analyzed. No group had both predicted and observed 9-month revascularization < or = 4% (very low risk). Conversely, 19 of 20 groups had a predicted and observed revascularization rate of 4-10% (low risk). In the real-world setting, the need for intermediate-term revascularization after BMS may be lower than expected, but it may be very difficult to identify patients at very low risk. Conversely, if the benefits of DESs are attenuated in routine practice, many groups of patients treated with BMSs may have nearly comparable results.

Is bare-metal stenting superior to balloon angioplasty for small vessel coronary artery disease? Evidence from a meta-analysis of randomized trials

AIMS

To compare, by meta-analytical techniques, the clinical impact of bare-metal stenting vs. balloon angioplasty for the treatment of lesions in small coronary arteries.

METHODS AND RESULTS

We included trials with random allocation and prospective comparison of angioplasty vs. stenting, reference vessel diameter<3 mm, and follow-up>or=6 months. Random effect odds ratios (OR) for death, myocardial infarction (MI), repeat revascularization (RR), and major adverse cardiac events (MACEs) were computed. In a pre-specified subgroup analysis, we compared stenting with optimal (post-procedural stenosis<20%) and suboptimal (>20%) angioplasty. Thirteen studies (4383 patients) were selected. No differences were found in terms of death and MI, while MACEs, mainly driven by RR, were significantly less common after stenting (17.6%) than after angioplasty (22.7%), OR 0.71 (0.57-0.90). Heterogeneity among trials was present. When considering only optimal angioplasty, MACE rates were homogeneously similar, 17.9 vs. 21.1%, OR 0.86 (0.66-1.11). If angioplasty were suboptimal, MACEs were significantly more common after angioplasty (24%) than after stenting (17.3%), OR 0.62 (0.44-0.88).

CONCLUSION

Stenting is superior to balloon angioplasty for the treatment of small vessels, in particular after suboptimal angioplasty. However, MACE and RR rates remain high after stenting, and the advantage of stent over angioplasty is moderate. An optimal balloon angioplasty strategy (with provisional stenting) may achieve results not inferior to routine stenting.

Health-related quality of life after interventional or conservative strategy in patients with unstable angina or non–ST-segment elevation myocardial infarction

OBJECTIVES

We sought to compare the effects of an early interventional strategy (IS) versus a conservative strategy (CS) on health-related quality of life (HRQOL) in patients with non-ST-segment elevation acute coronary syndromes (ACS).

BACKGROUND

The third Randomized Intervention Trial of unstable Angina (RITA-3) evaluated early IS (n = 895) versus CS (n = 915). We report one-year results of the RITA-3 trial concerning HRQOL.

METHODS

The patients' HRQOL was assessed with the Short Form-36 (SF-36) and Seattle Angina Questionnaire (SAQ) at four-month and one-year follow-up, and the EuroQOL Visual Analogue Scale (EQ-VAS) and EuroQOL 5-Dimensional Classification (EQ-5D) also measured at baseline. Analysis was performed using the two-sample t test and analysis of co-variance.

RESULTS

Mean changes from baseline EQ-VAS scores were better for IS than for CS at four months (treatment difference of 3.0, p < 0.001) and one year (2.3, p < 0.01). The EQ-5D utility scores were also higher for IS at four months (treatment difference: 0.036, p < 0.01) and at one year (0.016, p = 0.20). For SF-36, IS scored significantly better at four months for physical function, physical role function, emotional role function, social function, vitality, and general health. The SAQ scores for exertional capacity, anginal stability and frequency, treatment satisfaction, and disease perception were better for IS at four months. These treatment differences were present but attenuated by one-year follow-up. Improvements in HRQOL for IS could be attributed to improvements in anginal symptoms.

CONCLUSIONS

In patients with non-ST-segment elevation ACS, an early IS provides greater gains in HRQOL, as compared with CS, mainly due to improvements in angina grade.

Angioplasty and stents in coronary artery disease: a systematic review and meta-analysis

OBJECTIVES

To undertake a systematic review of the clinical effectiveness of routine percutaneous transluminal coronary angioplasty (PTCA) plus stenting vs PTCA alone.

DATA SOURCES

MEDLINE; EMBASE; Science Citation Index; The Cochrane Library; cardiovascular journals and conference proceedings; Internet resources (including industry supported web pages); and reference lists of included studies and relevant reviews.

REVIEW METHODS

Study selection included published and unpublished randomized controlled trials (RCTs) comparing the use of coronary stents to PTCA. Outcome measures assessed included death, acute myocardial infarction (AMI), event rate (such as major cardiac adverse events (MACE) or other composite measures), and binary restenosis (BR). Data extraction and quality assessment were conducted according to internationally recognized methods. Data synthesis included meta-analysis of assessed outcomes, reported as odds ratios (ORs).

RESULTS

Fifty RCTs involving 16,500 patients met the inclusion criteria (39 full articles, 11 abstracts). Of these, 23 studies compared stenting with PTCA in patients with non-specific coronary artery disease (CAD), 11 compared stents with PTCA following AMI, 8 included patients with small coronary arteries and 8 included patients whose vessels had chronic total occlusion. There were no differences in rates of death or AMI. There were reductions in the rates of MACE (death, AMI or revascularization) with stents compared to PTCA (at 6 months, for non-specific group OR: 1.64, 95% CI 1.44-1.87; for AMI group OR: 2.36, 95% CI 1.92-2.89; for small vessel group OR: 1.38, 95% CI 1.10-1.74; at 12 months, for non-specific group OR: 1.31, 95% CI 1.11-1.55; for AMI OR: 2.26, 95% CI 1.47-3.46). Reporting of combined major adverse cardiac events was inconsistent across studies. Most events were revascularizations that may have been partly driven by protocol-required angiograms. Stents reduced BR rates at angiogram at 6 months compared to PTCA in all groups.

CONCLUSION

We found no differences in mortality or AMI, but the studies were not powered to identify changes in these endpoints. Coronary stenting is associated with reduced restenosis and combined adverse cardiac events, primarily revascularizations. However, the frequency of revascularization may have been distorted by protocol-dictated angiography.

Willingness to pay for avoiding coronary restenosis and repeat revascularization: results from a contingent valuation study

BACKGROUND

Despite technological improvements, percutaneous coronary intervention (PCI) remains limited by restenosis requiring further revascularization procedures during the ensuing year. New technologies aiming to reduce restenosis are expensive and may increase net healthcare costs. Economic evaluations of such therapies have been performed, but have been hindered by the need to assess the disutility of short-term health care events and repeat coronary revascularization as well as the lack of benchmark standards for intermediate health outcomes. The contingent valuation approach may offer particular advantages when evaluating treatments that improve short-term health outcomes.

OBJECTIVE

To examine patients' willingness to pay (WTP) for treatments that may reduce the risk of restenosis and repeat revascularization after PCI.

METHODS

We used a contingent valuation approach to evaluate WTP among participants in two large clinical trials evaluating new PCI devices. The baseline scenario described a 30% probability of repeat revascularization following the initial procedure. Patients were asked to indicate, using a close-ended (referendum) question, their out of pocket WTP for an improved treatment that would reduce this risk. Three different prices (500 dollars, 1000 dollars, and 1500 dollars) and three levels of absolute risk reduction (10, 20, and 30%) were randomly varied creating nine sub-samples of patients. Patients' responses were analyzed using both parametric and non-parametric methods.

RESULTS

1642 patients completed the WTP question. The WTP medians for the 10 and 20% risk reductions were 273 dollars and 366 dollars, respectively; the median WTP for the 30% risk reduction was significantly higher at 1162 dollars (P<0.001). Higher household income (OR=1.57, P<0.001) was independently associated with a higher WTP.

CONCLUSIONS

Although short-lived, avoidance of coronary restenosis may have considerable value to patients undergoing percutaneous coronary interventions. These findings may have important implications for emerging technologies such as drug-eluting stents.

Prevention of restenosis after coronary angioplasty

PURPOSE OF REVIEW

Despite numerous advances in coronary interventional techniques, the frequent occurrence of restenosis continues to plague interventional cardiology. With the widespread use of drug-eluting stents, there is a need to reexamine critically the roles of the various interventional techniques currently available.

RECENT FINDINGS

Drug-eluting stents have dramatically reduced the rates of restenosis and target vessel revascularization in a wide spectrum of patients with varying lesion morphologies. However, when restenosis does occur, it still tends to be dependent on the same factors that predict restenosis with bare metal stenting. The routine use of drug-eluting stents entails high initial costs to the health care system. Debulking as a means to improve outcomes after angioplasty has not lived up to expectations. Gene therapy is rapidly evolving into a viable means to reduce neointimal proliferation after angioplasty.

SUMMARY

Careful patient selection and attention to the procedure of stent deployment optimize the results of angioplasty with drug-eluting stents. Because of cost considerations, drug-eluting stents should be used in patients who are expected to have the greatest absolute benefit. In this context, when judiciously used, conventional balloon angioplasty and bare metal stenting still have a definite role in the management of patients with obstructive coronary artery disease.

Impact of coronary artery stents on mortality and nonfatal myocardial infarction: meta-analysis of randomized trials comparing a strategy of routine stenting with that of balloon angioplasty

BACKGROUND

A strategy of routine stenting has been shown to reduce the need for target-vessel revascularization compared with a strategy of balloon angioplasty alone; however, the impact on mortality and frequency of nonfatal myocardial infarction is unclear. The aim of this study was to provide a quantitative comparison of the impact of coronary stenting on the rates of mortality and myocardial infarction with that of balloon angioplasty with provisional stenting.

METHODS

We performed a meta-analysis of randomized trials comparing routine coronary stenting to percutaneous transluminal coronary angioplasty (PTCA), including only those trials that used combination antiplatelet therapy (aspirin and a thienopyridine) as an adjuvant to stenting. Such trials included: the Belegian Netherlands Stent Study (BENESTENT) II, Optimal Coronary Balloon Angioplasty With Provisional Stenting Versus Primary Stent (OCBAS), Balloon Optimization vs Stent Study (BOSS), Evaluation of Platelet IIb/IIIa Inhibitor for Stenting (EPISTENT), Optimum Percutaneous Transluminal Coronary Angioplasty Compared With Routine Stent Strategy (OPUS-1), French Optimal Stenting Trial (FROST), Angioplasty or Stent (AS), and Doppler Endpoint Stenting International Investigation (DESTINI) trials for de novo coronary artery lesions; the Stent vs Percutaneous Angioplasty in Chronic Total Occlusion (SPACTO), Total Occlusion Study of Canada (TOSCA), Stent or Angioplasty after Recanalization of Chronic Coronary Occlusions (SARECCO), and Mayo-Japan Investigation for Chronic Total Occlusion (MAJIC) trials for coronary occlusions; the Primary Angioplasty Versus Stent Implantation in Acute Myocardial Infarction (PASTA), Gianturco-Roubin in Acute Myocardial Infarction (GRAMI), Florence Randomized Elective Stenting in Acute Coronary Occlusions (FRESCO), Immediate Coronary Angioplasty with Elective Wiktor Stent Implantation Compared with Conventional Balloon Angioplasty in Acute Myocardial Infarction (STENTUIM-2), Stent Primary Angioplasty in MI (Stent-PAMI), Zwolle, and Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trials for acute ST-segment elevation myocardial infarction; and the Intracoronary Stenting or Angioplasty for Restenosis Reduction in Small Arteries (ISAR-SMART), Park, Stenting in Small Arteries (SISA), and Bestent in Small Arteries (BESMART) trials for small vessels.

RESULTS

The 23 trials enrolled 10,347 patients, with 5130 patients randomized to receive stent and 5217 patients randomized to receive balloon angioplasty. A total of 902 (17 %) of patients crossed over from a strategy of balloon angioplasty to stent placement because of the inability to achieve a satisfactory result with a balloon. No significant difference was observed between the stent group and PTCA group in the rates of death or myocardial infarction, despite a significant reduction in the frequency of major adverse cardiac events (odds ratio, 0.59; 95% CI, 0.50-0.70; P <.001), which was driven entirely by a reduction in target vessel revascularization.

CONCLUSIONS

An initial strategy of stent placement versus balloon angioplasty with provisional stenting is associated with a similar mortality rate and frequency of nonfatal myocardial infarction after a mean follow-up period of 12.8 months. Patients who underwent stent placement had a significantly lower risk of major adverse cardiac events only when target revascularization is included as an end point.

Can we afford to eliminate restenosis?

Over the past decade, coronary stenting has emerged as the dominant form of percutaneous coronary revascularization. However, bare metal stents remain limited by a high incidence of restenosis, leading to frequent repeat revascularization procedures and substantial economic burden. Antiproliferative drug-eluting stents (DES) have recently demonstrated dramatic reductions in rates of restenosis, compared with conventional stenting, but important concerns about their costs have been raised. In this article, we summarize current evidence on the economic impact of restenosis and explore the potential benefits and economic outcomes of DES. In addition to examining the long-term costs of this promising technology, we consider the potential cost-effectiveness of DES from a health care system perspective and the impact of specific patient, lesion, and provider characteristics on these parameters.

Previous cytomegalovirus infection and restenosis after aggressive angioplasty with provisional stenting

The aim of this study was to determine the impact of previous with cytomegalovirus (CMV) on restenosis after aggressive angioplasty with provisional stenting.

DESIGN

We prospectively studied 78 consecutive patients scheduled for 6-month follow-up coronary angiography as part of the SIPS study. Anti-CMV IgG and IgM antibodies were measured on admission.

RESULTS

Anti-CMV IgG positive and anti-CMV IgG negative patients had similar minimal lumen diameter (MLD) in the target vessel before (0.68 +/- 0.49 mm vs 0.71 +/- 0.52 mm, P = 0.84) and directly after the intervention (2.50 +/- 0.60 mm vs 2.57 +/- 0.52 mm, P = 0.58). After 6 months, however, the MLD was significantly smaller in CMV-positive as compared to CMV-negative patients (1.57 +/- 0.82 mm vs 2.00 +/- 0.83 mm, P < 0.03). Net lumen gain at 6 months was significantly lower in CMV-positive patients (0.89 +/- 0.79 mm vs 1.30 +/- 0.87 mm, P < 0.04) and the rate of clinically relevant restenosis was significantly higher (31% vs 7%, P < 0.02). In a multivariate logistic regression model, CMV seropositivity was an independent predictor of restenosis (odds ratio 5.7 (95% CI 1.2-30.3, P = 0.04).

CONCLUSIONS

Six months after aggressive coronary angioplasty with provisional stenting, patients with prior CMV infection had a smaller MLD and a higher restenosis rate. CMV seropositivity was a strong independent predictor of restenosis.

Drug-eluting stent task force: Final report and recommendations of the working committees on cost-effectiveness/economics, access to care, and medicolegal issues

Coronary artery disease remains a major health problem worldwide. Since introduction of percutaneous transluminal coronary angioplasty and stents, much progress has been made. Percutaneous coronary intervention, however, has been limited by restenosis (repeat obstruction of arteries that have been previously treated. Introduction of drug-eluting stents (DESs) in April 2003 was a major breakthrough in preventing restenosis. In March 2003, The Society for Cardiovascular Angiography and Interventions (SCAI) published a position statement on the clinical implications of DESs, recommending an evidence-based adoption strategy. Subsequently, in May 2003, SCAI formed a multidisciplinary Drug Eluting Stent (DES) Task Force to address the significant nonclinical ramifications posed by DESs: medicolegal, financial, and access to care. The Task Force included representatives from physician societies, industry, academia, the reimbursement community, and health policy organizations. The resultant report presents analyses, options, and recommendations regarding those nonclinical issues based on the collective experience and knowledge of the Task Force members. The Task Force trusts that this report will be of value to the diverse constituencies involved with introduction of this important new technology.

Retroinfusion-supported stenting in high-risk patients for percutaneous intervention and bypass surgery: Results of the prospective randomized myoprotect I study

The objective of this study was to assess event-free survival and total treatment costs of retroinfusion-supported stenting in high-risk patients compared to bypass surgery. An increasing number of patients with main-stem and main-stem-equivalent stenosis are treated by stent implantation, which appears to be safe in the short-term follow-up. However, there is a lack of randomized studies comparing conventional bypass surgery with stent implantation, particularly in patients with high risk for both treatments. We here report on the 1-year results of a prospective randomized single-center study in patients with symptomatic main-stem and main-stem-equivalent lesions with substantially increased risk for bypass surgery. Patients where randomized to undergo either percutaneous transluminal coronary angioplasty/stent procedure (n = 23) or bypass surgery (n = 21). Patients randomized to stent implantation were supported by selective pressure-regulated retroinfusion of the anterior cardiac vein during ischemia. Patients of the stent group and the bypass group did not differ in baseline characteristics, including Parsonnet score and quality-of-life score. Twenty-eight-day mortality and 1-year mortality rate as well as quality-of-life scores were similar in both groups. Event-free survival after 1 year was higher in the bypass group (71.4% vs. 52.3%; P = 0.02) due to a lower target lesion revascularization rate. With regard to total treatment costs, however, the stent group compared favorably to the bypass group (9,346 +/- 807 vs. 26,874 +/- 3,985 euro), predominantly as a result of a shorter intensive care and hospital stay. In this first randomized study in high-risk patients for stent implantation and bypass surgery, patients with retroinfusion-supported stent implantation had a similar 1-year outcome and quality of life compared to patients with bypass surgery. Though in the stent group event-free survival was lower and target lesion revascularization rate was higher, retroinfusion-supported stent implantation was associated with substantially lower costs and might be considered as an alternative treatment option in this selected group of high-risk patients.

Outcomes of optimal or “stent-like”balloon angioplasty in acutemyocardial infarction: the CADILLAC trial

OBJECTIVES

We sought to compare outcomes between patients with acute myocardial infarction (AMI) undergoing percutaneous transluminal coronary angioplasty (PTCA) with an optimal or "stent-like" result versus patients who underwent routine stent placement.

BACKGROUND

Recent studies in patients with AMI undergoing stent implantation have suggested that PTCA may no longer be a relevant treatment modality for stent eligible lesions. However, whether routine stent placement is superior or necessary when an optimal PTCA or "stent-like" result is achieved is unknown.

METHODS

In the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial, 2,082 patients with AMI were randomly assigned to undergo PTCA alone, PTCA + abciximab, stenting alone, or stenting + abciximab. Outcomes were compared in patients achieving an optimal acute PTCA result (residual core laboratory diameter stenosis <30% without significant dissection) versus those assigned to routine stenting.

RESULTS

Optimal PTCA was achieved in 40.7% of patients randomized to balloon angioplasty, including 38.5% and 42.7% assigned to PTCA alone and PTCA + abciximab, respectively. Ischemic target vessel revascularization (TVR) at 30 days occurred more frequently after optimal PTCA than routine stenting (5.1% vs. 2.3%, p = 0.007). The one-year composite adverse event rate (death, reinfarction, disabling stroke, or TVR) was greater after optimal PTCA than routine stenting (21.9% vs. 13.8%, p < 0.001), driven largely by increased rates of ischemic TVR (19.1% vs. 9.1%, p < 0.001); no significant differences were present in the rates of death, reinfarction, or disabling stroke between the two groups. Angiographic restenosis also was more common with optimal PTCA than routine stenting (36.2% vs. 22.2%, p = 0.003). Even a post-PTCA diameter stenosis of <20% (realized in 12% of patients) did not result in outcomes equivalent to stenting.

CONCLUSIONS

Even if an optimal result is achieved after primary PTCA in AMI, early and late outcomes can be further improved with routine stent implantation.

Intravascular ultrasound-guided balloon angioplasty compared with stent: immediate and 6-month results of the multicenter, randomized Balloon Equivalent to Stent Study (BEST)

BACKGROUND

Balloon angioplasty guided by intravascular ultrasound (IVUS) makes it possible to choose the balloon size according to the true vessel diameter and to detect suboptimal results requiring subsequent stent implantation. The Balloon Equivalent to STent (BEST) study aimed to assess whether this strategy would give the same results as systematic stenting.

METHODS AND RESULTS

A total of 132 of 254 patients were randomized to IVUS-guided percutaneous transluminal coronary angioplasty (aggressive PTCA), and 122 were randomized to stenting (stent group). We hypothesized that a difference of <8% in the 6-month angiographic restenosis rate (primary end point) could be considered noninferior. The aggressive PTCA procedure was longer and had a greater use of contrast medium than stenting. In the aggressive PTCA group, crossover to stent was needed in 58 patients (44%). At 6 months, 20 of 119 patients (16.8+/-6.7%) in the aggressive PTCA group and 21 of 116 patients (18.1+/-7.0%) in the stent group had restenosis. The difference was -1.3%, with an upper limit of 95% confidence interval of 7.1% (ie, less than the noninferiority boundary). The in-stent restenosis rate was higher in the stent group (15.5% versus 5%; P=0.02). The differences in minimum lumen diameter, lumen cross-section area, and 1-year event rate were not significant.

CONCLUSIONS

A strategy of IVUS-guided angioplasty with provisional stenting is feasible and safe. At the cost of a more complex procedure, it reduces the stent rate by half, with similar 6-month angiographic IVUS and clinical outcome compared with stent implantation.

Cost-effectiveness of intracoronary ultrasound for percutaneous coronary interventions

The Strategy for Intravascular Ultrasound (IVUS) guided PTCA and Stenting trial included a prospectively designed economic analysis to investigate whether routine IVUS guidance intervention is cost-effective. Consecutive patients (n = 269) with 356 lesions were randomly assigned to receive provisional stenting with angiographic guidance only (ANGIO) or with IVUS guidance. The 2-year major adverse cardiac event-free survival (effectiveness) was significantly higher in the IVUS-guided group (80% vs 69%, p <0.04). In-hospital costs for procedural personnel, capital equipment, and disposable equipment were higher in the IVUS group. This was offset by lower costs for inpatient care and urgent target vessel revascularization in the IVUS group. Therefore, the total in-hospital cost was only slightly higher with IVUS (5,245 +/- $2,256 [IVUS] vs 4,776 +/- $2,961 [ANGIO], $/patient, p = 0.15). During a 2-year follow-up, costs for cardiac hospitalizations were slightly lower in the IVUS group, whereas costs for medication and indirect costs were similar. This resulted in identical total costs over the 2-year period (15,947 +/- $8,545 [IVUS] vs 16,103 +/- $9,954 [ANGIO], $/patient, p = 0.89). The incremental cost-effectiveness ratio for IVUS guidance calculated to -$1,417/major adverse cardiac event-free survival gained. In 55.3% of bootstrapping replications, IVUS was less expensive and more effective. In conclusion, when used in a provisional stenting strategy, routine IVUS imaging is cost-saving half the time.

Cost-effectiveness of gamma radiation for treatment of in-stent restenosis: results from the Gamma-1 trial

BACKGROUND

Recently, several randomized trials have demonstrated that intracoronary brachytherapy can reduce the rates of both angiographic and clinical restenosis in patients undergoing percutaneous coronary intervention (PCI) for in-stent restenosis. Whether this practice is cost-effective is unknown.

METHODS AND RESULTS

Between December 1997 and July 1998, 252 patients with in-stent restenosis were randomized to receive brachytherapy or placebo after successful PCI as part of the Gamma-1 trial. We collected detailed resource utilization and cost data for each patient's initial hospitalization and for 1 year after randomization. Compared with conventional treatment, intracoronary brachytherapy increased procedure duration, physician services, and equipment costs. As a result, initial costs were increased by nearly $4100 per patient ($15 724 versus $11 675, P<0.001). Over the 1-year follow-up period, brachytherapy reduced the need for repeat revascularization by 21% and reduced the need for bypass surgery by 44%. Although follow-up medical care costs were $2200/patient lower with brachytherapy, total costs remained higher at 1 year ($28 543 versus $26 737, P=0.46). In a sensitivity analysis that incorporated recent technical modifications and the use of prolonged antiplatelet therapy to prevent late thrombotic occlusion, follow-up cost savings increased to $3600/patient, and 1-year costs were slightly lower with brachytherapy ($26 352 versus $26 729, P=0.87). Subgroup analysis demonstrated significant cost savings in patients with diabetes and patients who did not undergo repeat stenting.

CONCLUSIONS

As performed in the Gamma-1 trial, coronary brachytherapy for in-stent restenosis improved clinical outcomes but increased 1-year costs compared with standard therapy. If late thrombosis can be eliminated, however, this technology has the potential to reduce overall medical care costs.

Resource utilization, cost, and health status impacts of coronary stent versus "optimal" percutaneous coronary angioplasty: results from the OPUS-I trial

In the OPUS-I trial, primary coronary stent implantation reduced 6-month composite incidence of death, myocardial infarction, cardiac surgery, or target vessel revascularization relative to a strategy of initial PTCA with provisional stenting in patients undergoing single vessel coronary angioplasty. The purpose of this research was to compare the economic and health status impacts of each treatment strategy. Resource utilization data were collected for the 479 patients randomized in OPUS-I. Itemized cost estimates were derived from primary hospital charge data gathered in previous multicenter trials evaluating coronary stents, and adjusted to approximate 1997 Medicare-based costs for a cardiac population. Health status at 6 months was assessed using the Seattle Angina Questionnaire (SAQ). Initial procedure related costs for patients treated with a primary stent strategy were higher than those treated with optimal PTCA/provisional stent ($5,389 vs $4,339, P < 0.001). Costs of initial hospitalization were also higher for patients in the primary stent group ($9,234 vs $8,434, P < 0.01) chiefly because of the cost differences in the index revascularization. Mean 6-month costs were similar in the two groups; however, there was a slight cost advantage associated with primary stenting. Bootstrap replication of 6-month cost data sustained the economic attractiveness of the primary stent strategy. There were no differences in SAQ scores between treatment groups. In patients undergoing single vessel coronary angioplasty, routine stent implantation improves important clinical outcomes at comparable, or even reduced cost, compared to a strategy of initial balloon angioplasty with provisional stenting.