Expensive, newer stents not better for all patients

Many heart patients get newer, pricey stents inserted during artery-clearing procedures, even if it's not clear they'd be worse off with more basic models, a new study suggests.

Along with being more costly, so-called drug-eluting stents require patients to take aspirin and other blood-thinning drugs for a longer period of time after their procedure - which may mean they have to put off future elective surgeries because of bleeding risks, according to one researcher who worked on the report.

Some patients having a stent inserted are at high risk of having that stent get clogged up, requiring a repeat procedure. In those patients - such as people with diabetes or narrow arteries - drug-eluting stents can help prevent build-up in and around the stent and avoid future surgeries, said Dr. Robert Yeh, a cardiologist from Massachusetts General Hospital in Boston.

But in people whose stents probably won't get clogged up to begin with, old-fashioned bare-metal stents can work just as well at a much lower price, he said. "Non-diabetic patients who have big arteries and have very short blockages, their rate of restenosis can be quite low, even with bare-metal stents," Yeh told Reuters Health.

"Patients need to ideally know an estimate of their individualized risk of requiring a repeat procedure, and they need to know, what are the implications of the different stent choices they might receive?"

For the new study, Yeh and his colleagues consulted data on 1.5 million patients having a stent inserted between 2004 and 2010 in the United States. Almost three-quarters of patients at very low risk of needing a repeat stent-inserting procedure received drug-eluting stents. That compared with 83 percent of the higher-risk patients, who had more to gain from the extra protection offered by those newer stents.

What's more, doctors varied greatly in their use of drug-eluting stents: Individual surgeons used the newer devices for between two and 100 percent of procedures. Yeh's team calculated that if half of low-risk patients given a drug-eluting stent instead received a bare-metal stent, the U.S. could save over $200 million per year on heart procedures, or about $340 per procedure.

As a result, an extra one in 200 patients given a bare-metal stent would eventually need a repeat artery-clearing procedure, the researchers reported Monday in the Archives of Internal Medicine.

Yeh said some doctors may assume the newest stent available is the best one for their patients. But researchers emphasized the need for people going in for elective heart procedures to discuss their options with their surgeons.

"This is definitely a case where you can't have a general rule that applies in every situation," said Dr. Jack Tu, head of cardiovascular research at the Institute for Clinical Evaluative Sciences in Toronto, who wasn't involved in the new study.

"The higher-risk patients should be getting these (drug-eluting) stents, whereas I think an argument could be made that lower-risk patients should be getting bare-metal stents."

But, he told Reuters Health, "It really should be an individualized decision and should take into account the risk of getting a drug-eluting stent as well as the benefits."

The downsides of the newer stents include costs and possible consequences of being on blood thinners for about a year, compared to a month after receiving a bare-metal stent. Dr. Peter Groeneveld, who wrote a commentary accompanying the study, said the new findings are just one example of ways technology gets overused and at times misused in healthcare.

"All the incentives are aligned right now to use the most expensive, newest therapeutic options when often there are much cheaper, tried and true, evidence-based therapies that are going to deliver just as much benefit," Groeneveld, from the University of Pennsylvania in Philadelphia, told Reuters Health.

"If you get an expensive stent, somebody has to pay for it, even if that stent doesn't benefit anybody, including the patient, anymore than a cheaper alternative," he added. In that case, Groeneveld added, "That's just money down the drain."