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
