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Drug-eluting stent use declined more than 30% between 2006, 2008
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Patterns of drug-eluting stent use changed after a public debate related to scientific publications and presentations on their safety.
The researchers examined temporal patterns of drug-eluting stent use in 54,662 patients with non-STEMI who were enrolled in the CRUSADE and ACTION–GWTG registries. Among those, 27,329 underwent percutaneous coronary intervention from 2006 to 2008. The number of hospitals that participated in either registry varied between 171 and 208, with 125 hospitals participating in both registries.
The researchers observed a decline in drug-eluting stent use during the fourth quarter of 2006 that continued throughout 2007 and into the first quarter of 2008. Drug-eluting stent use in the 125 hospitals participating in both registries decreased steadily from around 90% in the third quarter of 2006 to 59% by the first quarter of 2008. Concurrently, the use of bare metal stents increased from around 10% in the third quarter of 2006 to slightly more than 40% in the first quarter of 2008.
The same trend was observed when all hospitals were evaluated, with drug-eluting stent use decreasing from around 90% in the third quarter of 2006 to just less than 60% by the first quarter of 2008. Bare metal stent use increased from around 10% in the third quarter of 2006 to slightly more than 40% in the first quarter of 2008. There was an increase (from 58% to 60%) in the use of drug-eluting stents in all hospitals between the first and second quarters of 2008.
“The rapid changes in practice patterns demonstrated in this analysis suggest that a collaborative partnership between the public media, professional societies and academic organizations is needed to accurately distill and disseminate pivotal scientific information that has the potential to rapidly influence both physicians and patients,” the researchers wrote. – by Eric Raible
Roe MT. Circulation: Cardiovascular Quality and Outcomes. 2009;doi:10.1161/CIRCOUTCOMES.109.850248.
This paper is interesting because it reflects, as the researchers point out, how quickly practice patterns can change in the face of public debate. It is extraordinary that drug-eluting stent use fell so dramatically in the face of data that were iffy at best and problematic at worst — and ultimately wrong when proven to be so two years later. What was pushing doctors to change their total practice patterns in the face of inadequate data? One answer may be that it is a result of defensive medicine, where physicians think there is a potential that drug-eluting stents are more dangerous than bare metal stents and stop using them — even without data that are adequate, supportive or real. I find that extraordinary.
So why is it that we know that drug-eluting stents are no worse than bare metal stents and that the restenosis rates of drug-eluting stents are actually lower than with bare metal stents, but we do not give people more drug-eluting stents like we did in 2005? Why are we doing something that may not be in the best interest of some patients, whereas we do it in the best interest of others? These questions crossed my mind when I read this paper. This of course can get really dicey, but it is an interesting philosophical argument that this paper raises.
– Peter C. Block, MD
Cardiology Today Section Editor