Drug Eluting Stents

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Drug Eluting Stents The Wrong therapy for
Vulnerable Plaque
RS Schwartz Minneapolis Heart Institute
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• A 3-Part Argument
• There are no data yet
• VP Detection and Economics
• The Strategy is wrong

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• FACT
• Drug Eluting stents appear to form a healthy
  neointima
• The restenosis rate may be 8-10

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• FACT
• Long term results are pending
• We have no data for mild disease or Vulnerable
  lesions

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• Argument 1
• There is simply no evidence that the drug eluting
  stent will fix the vulnerable plaque problem.

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• FACT
• Drug Eluting stents will initially cost about
  3,000 each.

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• FACT
• Sensitivity and Specificity for Detection are
  unknown but will likely be poor
• ??40- 50

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• FACT
• If a typical patient has 3-4 such plaques, a
  single session will cost 12,000 in stents alone

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• FACT
• Including all asymptomatic patients, there may be
  2,000,000 candidates. At 12,000 each, this will
  be 24,000,000,000
• in stents alone

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• Argument 2
• Stenting every vulnerable plaque will break the
  National Budget.
• Which Lesions to stent and which to ignore?

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• Fact
• Vulnerable Plaque is a multifocal and possibly
  diffuse disease

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• Fact
• Vulnerable Plaque is a systemic disease

Multicentric inflammation in epicardial coronary
arteries of patients dying of acute myocardial
infarction.Spagnoli LG, Bonanno E, Mauriello A,
Palmieri G, Partenzi A, Sangiorgi G, Crea F. J
Am Coll Cardiol 2002 Nov 640(9)1579-88
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• Spagnoli et al
• 3 Groups, Autopsy pts Acute MI Old MI No CAD
• Cell Suspensions of all 3 coronary arteries

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• Spagnoli et al
• Flow Cytometry Lymphocytes SMC CD3/CD68

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• Spagnoli et al
• Results Diffuse lymphoctye activation in all 3
  arteries of Acute MI patients

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Patient 4, Stable, NZMaxT Difference Map of RCA
.25
.2
.15
MaxTdiff
.1
.05
0
Distal MID
Prox
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• Fact
• We just spent 12 years developing Drug Eluting
  Stents as a LOCAL therapy

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• Fact
• Roxs own data argues against stents
• The 1 year recurrent MACE in Acute Coronary
  Syndromes with PCI may be as high as 20

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• Rhetoric
• Treating a systemic disease with a local therapy
  makes no sense.

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• Argument 3
• It is folly to treat a diffuse problem with a
  focal therapy.
• We must instead develop simple therapies for the
  entire coronary tree.

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• Shootem all boys, the Devil will sort them
  out
• Clint Eastwood, 1972

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• Strategy
• Rearrange the cellular mileu of the entire
  coronary tree.
• Treat the disease, not the lesions.

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• Summary
• 1. No efficacy data in mild/minimal disease
• 2. We cant afford to treat with Drug Eluting
  Stents
• 3. It is folly to treat a diffuse problem with a
  focal therapy.

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• Axiom
• In any debate, present your case simply and
  cogently.
• Then personally savage your opponent.

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• Positions
• Photographs
• Motherhood
• Lennox Hill Hosp
• Iranian