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Shortcut or dead end street?
- Michele Coceani (13 March 2007)
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Drug eluting stents : A slap on the face of Evidence based cardiology . . .
- Venkatesan sangareddi (13 March 2007)
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Michele Coceani, Cardiologist CNR Institute of Clinical Physiology, Via Moruzzi 1, 56124 Pisa, Italy
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I was rather confused by the title of a recent “Shortcuts from other journals” which read “Drug eluting stents: risks of late restenosis sustained for up to three years”. Because I do not have full access to the Journal (I would like to point out that I began reading the BMJ when it was still open access and, even though the policy has changed in the meantime, my interest in the Journal has not), I was able to read only the extract of the article. Nevertheless, I came to the conclusion, on the basis of the available text, that the author was, in fact, affronting the issue of stent thrombosis, and not instent restenosis. The distinction between these two clinical entities is of extreme importance and should not be overlooked for several reasons. First of all, stent thrombosis determines an abrupt coronary occlusion which leads to myocardial infarction, or even sudden death, whereas instent restenosis causes a progressive decline in coronary lumen diameter which manifests typically with exertional angina. Secondly, after percutaneous coronary intervention, patients must be treated with two platelet inhibitors to permit complete endothelialisation of stent struts and, consequently, to avoid thrombosis.(1) The duration of such a therapy after the deployment of a drug-eluting stent is subject of intense debate, but probably should not be inferior to one year.(2) Instent restenosis, on the other hand, cannot be effectively prevented by antiplatelet therapy, or by any other type of pharmacological intervention.(3) However, all patients who have undergone stenting should be administered aspirin for life to protect against subsequent coronary events.(4) A clear understanding of these facts is fundamental, not only for cardiologists, but also for general practitioners and specialists without specific interests in cardiology who read the BMJ and inevitably encounter patients with ischaemic heart disease during their routine clinical practice. References 1. Silber S, Albertsson P, Aviles FF, Camici PG, Colombo A, Hamm C, et al. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 2005; 26: 804-47. 2. Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: A science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 2007; 115: 813-8. 3. Garas SM, Huber P, Scott NA. Overview of therapies for prevention of restenosis after coronary interventions. Pharmacol Ther 2001; 92: 165- 78. 4. Patrono C, Bachmann F, Baigent C, Bode C, De Caterina R, Charbonnier B, et al. Expert consensus document on the use of antiplatelet agents. The task force on the use of antiplatelet agents in patients with atherosclerotic cardiovascular disease of the European society of cardiology. Eur Heart J 2004; 25: 166-81. Competing interests: None declared |
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Venkatesan sangareddi, Assistant professor of cardiology Madtras medical college
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Drug eluting stents : A slap on the face of Evidence based cardiology . . . It is often said science is sacred and unfortunately we forget , after all science is not a heavenly creation and it is the creation of scientist of varying grades of integrity fueled by the vested interest of medical industry . It has been a almost a daily affair , some of the devices and drugs are recalled or found to be unsafe on patients. Now the big cat has come out .The Drug eluting stent has fallen from Hero to Zero in a short span of 5 years. It was projected to have zero percent restenosis in 2002 . And now we realize it is Zero percent truth. What has started as anecdotal reports of late stent thrombosis has indeed become an epidemic in all DES patients. The five studies that has been published in the NEJM this month (March 2007) has convincingly proved how unsafe these stents are in most of the coronary population . Millions of patients in whom this stent was implanted will carry an impending stent thrombosis and possibly an SCD . Who is to take care of them ? The DES story is a clear cut case of getting premature approval for a dangerous form of treatment inside human coronary arteries. It is amazing how the scientist’s eyes are shut by the illusion of knowledge and lure of wealth. How foolish they were to think drug which was administered via the stent will selectively prevent vascularisation and leave the normal endothelium intact . Now they realized , one should not suppress the endothelial growth around the stent and got the fundamental point wrong. Which was the key reason for the astonishing episodes of late stent thrombosis. When we play with biology of nature we have to be little more careful .God has created man and his heart for over a million years . One can not alter it by a 6 month follow up study of DES . When ICDs were exposed last year , of similar disastrous outcome they were recalled and explanted . How are we going to unstent the millions of coronary arteries ? Somewhere along the line the medical professionals have lost the battle against the Wall street and NASDAQ . Or how else we can explain repetition of similar events. The wages for the modern technology , the patients have to pay a heavy price. Let us all hope common man with common sense will reign supreme over the sixth sense of the uncommon man . . . "Ignorance is better than illusion of knowledge" Dr Venkatesan Sangareddi MD , Assistant Professor of cardiology , Madras medical college Chennai, India Competing interests: None declared |
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