ESC Congress 2003: New drug-eluting stents: enthusiasm sobered by economic constraints

A huge wave of enthusiasm was produced in the cardiological community by the results obtained with drug-eluting stents in patients with narrowings in the coronary arteries. Balloon coronary angioplasty was introduced approximately 25 years ago to reopen narrowed or occluded coronary arteries. Even though the use of stents has brought major improvements, recurrence rates of the narrowing ("restenosis") as high as 10 to 40% were still observed and truly constituted the 'Achilles heel' of the procedure. In the last two decades a great deal of effort and money has been expended evaluating an endless list of failed strategies, devices, and drugs to decrease restenosis. Therefore, the publication of restenosis rates close to zero after implantation of new stents coated with medication (drug-eluting stents) produced a lot of excitement: restenosis was defeated and a larger number of patients could benefit from stenting instead of surgery without fearing the daunting problem of restenosis.

In practice, however, little has changed. Only a very limited number of patients benefit from this medical breakthrough even though drug-eluting stents are becoming commercially available. The reason therefore is economic: drug-eluting stents cost approximately 3 times as much as their regular counterpart and, in most European countries, this larger costs are not borne by incremental reimbursement.

With accumulating evidence of (cost-)efficacy of drug-eluting stents, reimbursement is likely to increase. In addition, with growing competition between manufacturers, the list price of the drug-eluting stent will hopefully decrease. Nevertheless, in many countries and for several years, drug-eluting stents will be reserved to a select group of patients. Interventional cardiologists will find themselves with the difficult, and somewhat frustrating, task of weighing up what is an acceptable cost for a hypothetical benefit in the patients they have to treat.

Patients likely to benefit most from drug-eluting stents are those in whom the restenosis process is associated with increased mortality as well as those in whom the treatment of the restenosis is particularly difficult or expensive. On top of the list are diabetic patients, patients with a stenosis in the left main stem and patients with complicated bifurcation stenosis. Overall, however, things will only change really drastically when (cost-)efficacy of drug-eluting stents is proven in patients with narrowings in all three coronary arteries. At present, most of them have to undergo bypass surgery. Studies are on their way to evaluate whether these patients could be treated at least as well with drug-eluting stents than with bypass surgery. Only then, the "drug-eluting stent revolution" will come true for patients with coronary artery disease.

Bernard De Bruyne, MD
Cardiovascular Center Aalst
Belgium

European Society of Cardiology (ESC)

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ESC Congress 2003: New drug-eluting stents: enthusiasm sobered by economic constraints

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