The Choice Of Optimal Coronary Stents: Is It Possible To Maximize Cost-Effectiveness?

Authors: Rajeev Gupta, Neelesh Gupta, Shukri Saliba Shukri Mushahwar, Abdullah Mohammed Shehab

Percutaneous coronary interventions (PCI) with implantation of the stent have become standard-of-care in the management of obstructive coronary artery disease (CAD), including amongst patients with acute coronary syndromes (ACS). The most expensive hardware in PCI is drug-eluting stent (DES), thus making PCI an expensive affair; leading to unaffordability in many parts of the world. We made an attempt, to identify improved cost-effective ways to substitute DES with bare-metal stent (BMS) as and when feasible, while preserving the interests of the patients. While for patients with unstable CAD, DES is superior to BMS in device-oriented outcomes (unlike in patientoriented outcomes); patients with stable CAD with lesion (type A/B1 morphology) with coronary vessels larger than or equal to 3.75 mm: BMS is as good as second-generation DES, in both patient-oriented composite outcomes (all-cause death, any myocardial infarction, MI; and revascularization) and in device-oriented composite outcomes (cardiac death, target vessel MI, or symptom-driven TLR) both in shortand long-term follow-up. For patients with very-high risk of bleeding, irrespective of the cause of bleeding: BMS may be preferred with a view to reducing bleeding complication (as major bleeding adversely affects prognosis). Prefer no stent strategy i.e., only plain old balloon angioplasty (POBA) as and when possible like for patients with focal tandem stenotic-aneurysmal lesions and in diabetic patients with acute coronary syndromes with triple-vessel disease (planned for coronary artery bypass, POBA to relieve the obstruction to achieveing TIMI 3 flow, if possible). Replace temptation of oculostenotic reflex with the objective assessment of ischemia with flow fractional reserve (FFR) for lesions between 50% and 90%, particularly in stable CAD. Of course, for patients with obstructive left main stem (LMCA) disease and for bifurcation lesions (needing 2 or more stent strategy), and for lesions with Type B2 / C morphology, use of DES (preferably secondgeneration) to improve both patient-oriented and device-oriented outcomes is cost-effective and is recommended. You can submit your Manuscripts at:

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[v1] 2017-08-24 01:48:11

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