Cardiovascular Business - January/February 2009 - (Page 18)

Patient ManageMent both studies. However, Mehran notes that they were not powered to answer this question definitively. Williams points to the results from the MASS-DAC Registry, presented at the 2008 American Heart Association (AHA) meeting, that showed diabetic patients implanted with DES had an edge over those implanted with BMS. “The carefully worded conclusion said that DES were associated with a lower risk of mortality, MI and revascularization compared to BMS at two years, but the researchers were cautious not to use the words ‘better’ or ‘superior’,” Williams notes. DES always show less repeat revascularization, so initial procedures are more durable. “DES provides an overall benefit for death and MI, but that has not been conclusively proven,” he says. MASS-DAC also was an observational study, which allows physicians to use judgment about treatment rather than rely on randomization. Williams suggests that physician judgment could play a crucial role. “Patients with multivessel disease, be they diabetics or not, are different, and it’s wrong to put them all in the same group,” he says. In SYNTAX, for example, which compared DES to surgery, the pathology in the triple-vessel disease subgroup varied, including three vessels partially blocked, two vessels totally blocked and one vessel partially blocked. “In those with the most severe triplevessel disease, there is no difference for death, MI or repeat revascularization at one year compared to surgery,” Williams notes. Many clinicians are awaiting the results of the FREEDOM trial > Cost Considerations for Treating Diabetics with Multivessel Disease the initial costs associated with coronary artery bypass graft (CaBg) surgery are much higher than with PCi, because patients spend time in the iCU and have a prolonged hospital stay. While the length of stay for a stent patient is typically one night, the initial cost benefits gained with stenting could be lost in repeat procedures, especially in the high-risk diabetic population, according to David O. Williams, MD, chief of interventional cardiology at Rhode island Hospital in Providence. J. Dawn abbott, MD, a cardiologist at Rhode island Hospital, presented a study at the 2008 American Heart association conference that found many repeat procedures have nothing to do with the original procedure, but more to do with the progression of the patient’s disease. an analysis by Cohen et al found that DeS are costeffective in patients estimated to have a clinical restenosis rate greater than 12 to 14 percent (J am Coll Cardiol 2003;41[Suppl A]:32A). The calculations were strongly dependent on the price of DeS and reimbursement, both of which have changed since the publication of the analysis: the price of DES has declined and reimbursement has improved. the aRtS trial also found that the strategy of multivessel stenting of diabetic patients was less costly than CaBg, regardless of diabetic status. the total one-year costs in diabetic patients for stenting and CABG were $12,855 and $16,585, respectively, and $10,164 and $13,082, respectively, for nondiabetics (Circulation 2001; 104:533 -538). Michael Farkouh, MD, a cardiologist at Mount Sinai School of Medicine in new York City, suggests that the cost-effectiveness of stenting and CaBg is comparable in diabetics with multivessel disease, but among nondiabetics who require fewer stents and less revascularization, PCi is most likely more cost-effective. 18 Cardiovascular Business January/February 2009

Table of Contents Feed for the Digital Edition of Cardiovascular Business - January/February 2009

Cardiovascular Business - January/February 2009 Contents First Word Electrophysiology Roundtable Forum: A Candid Conversation about Profits, Procedures and Patients Heart Failure Care Gets Boost from Technology Emerging Technologies in Peripheral Vascular Interventions Stent vs. Graft: Choosing the Best Path for the Diabetic Patient with Multivessel Disease Cardiology Groups and Hospitals Strive to ‘Connect’ Seamlessly CT Beyond 64 Slices Clinical Study Digest: Kidney Disease & PCI; Women and Valve Disease Compact Echo Systems Come Up Big in Cardiac Care News & Views Reader Resources The ACC Corner

Cardiovascular Business - January/February 2009

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