Cardiovascular Business - September/October 2008 - (Page 27) Des Penetration in the U.s. 69 67 65 Percent 63 61 59 57 55 3/07 4 5 6 7 8 9 10 11 12 1/08 2 3 68.1 67.9 66.8 65.2 64.8 63.8 62.1 62.6 61.1 61.7 62.7 Between the last quarter of 2007 and the first quarter of 2008, the stent industry saw four consecutive months of increased drug-eluting stent use in the u.s. source: cRt 66.9 64.3 9.5% increase a cumulative incidence of angiographically documented stent thrombosis of 2 percent at three years—24 acute, 125 subacute and 152 late (J Am Coll Card 2008;51:986-990). Researchers found no differences between paclitaxel-eluting and sirolimuseluting stents. According to the researchers, they also conducted the largest subgroup analysis of 14,120 cases. They found that independent predictors for acute/subacute thrombosis were acute coronary syndrome, STEMI, renal failure, stent in left anterior descending artery (LAD), stent length, and diabetes. For late thrombosis, independent predictors were STEMI, stent in LAD, and stent length. Additionally, early discontinuation of antiplatelet therapy was a relatively common finding in patients with late ST. Second-generation stents De la Torre-Hernández says that they are currently continuing with the ESTROFA for second-generation DES, including Abbott’s XIENCE V and Medtronic’s Endeavor and they continue to find fewer cases of ST. He attributes the decrease to a better selection of those candidates who should receive DES. “We are more aware of patients who may have problems with antiplatelet therapy. We are learning to use more IVUS [intravascular ultrasound] during the stenting procedures, more overdilation of the stents. We have learned how to properly manage patients with DES now, and we are likely to see less stent thrombosis in the coming years,” de la Torre-Hernández explains. If the patient is properly chosen, the rates for stent thrombosis will be very low—below 1.2 percent a year, according de la TorreHernández. In a separate retrospective cohort study that also appeared in JACC, Peter W. Groeneveld, MD, from the Philadelphia Veterans Affairs Medical Center, and colleagues found that DES receipt was associated with fewer subsequent revascularization procedures, lower rates of hospitalization for acute MI (AMI) and improved survival among elderly Medicare beneficiaries (2008; 51:2017-2024). Groeneveld et al found that the receipt of a DES was associated with a significant survival benefit, with an adjusted mortality hazard ratio of 0.83 compared with contemporary controls, and a hazard ratio of 0.79 compared with historical controls. Patients with DES had significantly lower adjusted rates of revascularization procedures within the first two years after PCI and lower hospitalization rates for subsequent AMI. The study implies, the researchers wrote, “that DES have previously unrecognized clinical value in reducing mortality, although this effect may be confined to, or substantially more pronounced among, elderly patients.” Based on the positive DES findings of these studies, many experts think it will lead to an increase in utilization, despite the drop-off in PCI procedures in the past several years. “The studies comparing bare-metals with DES, the studies done with XIENCE V and Endeavor are all very positive. I think their use will increase, not maybe reaching the 90 percent rate in 2004-2005, but maybe reaching 80 percent usage,” de la TorreHernández says. CardiovascularBusiness.com Cardiovascular Business 27 http://CardiovascularBusiness.com
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