Long-term Outcomes in Patients Undergoing Percutaneous Coronary Intervention with Drug-eluting Stents

Roberta Rossini; Giuseppe Musumeci; Alessandro Aprile; Orazio Valsecchi

Disclosures

Expert Rev Pharmacoeconomics Outcomes Res. 2010;10(1):49-61. 

In This Article

Cost–effectiveness of DES

Drug-eluting stents might be considered cost effective if the additional cost (compared with BMS) is counterbalanced by outcome benefits. The reduction of the rate of repeat revascularization in DES-implanted patients significantly reduces long-term costs. However, there is no evidence of superiority of DES over BMS in terms of mortality and MI. The reduction in event rate in patients treated with DES is primarily made up of increased TLR and TVR due to stent restenosis. In most RCTs, TVR and TLR were angiographically driven rather than clinically driven, which does not reflect the daily clinical practice in the real world. In-stent restenosis is suspected in cases of new-onset angina and/or positive stress test. The concomitant therapy with β-blockers and nitrates may significantly reduce ischemia, thus contributing to further reduction of TVR and TLR.

The use of DES would be best targeted at the subgroups of patients with the highest risks of requiring reintervention, and could be considered cost effective in only a small percentage of such patents.[72] Moreover, the cost–effectiveness analyses often concentrate on DES made by big industries. There are numerous Asian competitor products that are available and may alter the balance of cost–effectiveness.

Finally, a more accurate selection of patients undergoing PCI both in RCT and in the real world is advisable. Any potential benefit on long-term outcomes adjudicated from DES or other technologies may be swamped by numbers of nonhemodynamically significant lesions being treated and also vice versa, particularly in the moderate range. Hence, a difference in long-term outcomes may be diluted.

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