Courtesy of Dr. Guillermo Migliaro.

Drug eluting stents (DES) represented the greatest technological advance in the treatment of instent restenosis from conventional metallic stents (BMS), especially cobalt chromium everolimus eluting stents (CoCr EES), which have shown an excellent profile, and are mostly safer, compared to first generation DES.

Indeed, several randomized studies and meta-analyzis have shown CoCr EES have reduced instent stenosis (ST), the need for repeat target vessel (TVR) revascularization, acute myocardial infarction (AMI) and cardiovascular mortality, compared to BMS.

However, the cost effective ratio has shown contradicting results.

The aim of this study was to analyze the cost-effective ratio of CoCr EES compared to BMS in coronary angioplasty procedures. 

It included data from five randomized studies (n= 4896) and assessed population baseline characteristics, intervention outcomes (mortality, instent restenosis, AMI and TVR) and the associated costs (provided by the Medicare program), expressed in American dollars. These last costs included the procedures (including stents), reinterventions (myocardial revascularization surgery or new PCI with or without stents and/or acute myocardial infarction) and dual antiaggregation therapy during two year follow up.

Patient mean age was 67 (76% were men) and 19% were diabetic. 44% of stents were placed during primary PCI and 87% were used in acute coronary syndromes.

The study outcomes showed CoCr EES were more effective than BMS, results mainly driven by reduced mortality (2.7 vs. 4.1%), ST (0.6 vs. 1.4%), AMI and TVR (4.3 vs. 10.2%). As regards costs, CoCr EES saved U$S 236 per patient, mainly because of TVR and AMI reduction, which offset the increased costs of the index procedure and DAPT observed with Co-Cr EES vs. BMS.

The study concluded that in the contemporary daily practice of PCI in USA, the use of CoCr EES was more effective and less costly than the use of BMS.

Editorial Comment

This work was the first to document an economical advantage to the use of CoCr EES compared to BMS.

It is important to spread the word especially among financing institutions and health care providers that will only take into account index procedure costs when defining medical insurance coverage (which are obviously higher in patients undergoing DES stenting), with no regard for the higher long term cost of BMS and their lower efficacy, compared to CoCr EES. 

Courtesy of Dr. Guillermo Migliaro.

Original Title: Cost effectiveness of percutaneous coronary intervention with cobalt chromiun everolimus eluting stents versus bare metal stents: results from a patient based metanalysis of randomized trials.

Reference: Ferco N et al. Cather Cardiovasc Interv 2017;89:994-1002.

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