DrRich Comments:
The data presented last week adds much fuel to the fire, and leaves both cardiologists and patients wondering what to do about DES. These stents have clearly made a huge impact in reducing the difficult problem of restenosis - which is why cardiologist so enthusiastically embraced them in the first place. However, it now seems plain that late thrombosis with DES is a real phenomenon, one that may affect long-term outcomes, and one that presents no easy answers.
The risk of late occlusion is very small (apparently, approximately, 1 in 200), especially compared to the risk of early restenosis with bare metal stents (which can be as high as 15 - 30%), but when it occurs it can happen quite suddenly, and can rapidly lead to heart attack or death.
The prolonged use of clopidogrel (Plavix) greatly reduces the risk of late thrombosis in DES, but clopidogrel itself poses problems. Aside from the expense and the risk of bleeding posed by the long-term use of this drug, using clopidogrel (because of the pronounced bleeding tendency it causes) essentially precludes any invasive medical procedures whatsoever. The drug must be stopped for several days prior to any such medical procedures, and some cardiologists are now very reluctant to allow their patients to do so, for at least a year or two after the DES is implanted.
The problem of late occlusion with DES will no doubt be resolved with future generations of stents. Several companies are developing a new varieties of DES for which this problem is expected to be greatly reduced. But for now, patients who need treatment for coronary artery disease should discuss with their doctors all the pros and cons of the various forms of therapy - medical, surgical, and stenting.
The discovery of late occlusions with DES is not a unique issue - virtually all medical therapies carry some risk of both early and late side effects. DES will still be the best option for many patients with coronary artery disease. But patients should make sure their doctors are taking this question fully into account when recommending therapy.
The bottom line, of course, is that once you've got coronary artery disease there are no perfect solutions. It is far, far better to deal with this issue by altering your lifestyle to reduce your risk for coronary artery disease before problems develop.
Disclosure: DrRich is a consultant for Boston Scientific Cardiac Rhythm Management.
Sources:
Wood, S. Studies linking drug-eluting stents to increased mortality/MI spark impassioned pleas for reason and calls for calm. TheHeart.org September 4, 2006 http://www.theheart.org/article/736863.do (registration required)
Murphy, S. Drug-Eluting Stent Late Thrombosis Meta-Analysis (Drug-Eluting Stent Late Thrombosis Meta-Analysis) http://www.cardiosource.com/pops/trialSum.asp?trialID=1481 (registration required)
Westphal SP and Winslow R. Boston Scientific Acknowledges Risks Tied to Stent. Wall Street Journal, Sept. 7, 2006. See: http://online.wsj.com/article/SB115759122980255909.html?mod=health_hs_medical_products (subscription required).
