Cost-benefit of drug eluting stents--time for a reality check

Drug-eluting stents (DES) are currently being used in preference to bare stents in the public hospital system in 'high risk' lesions on the basis of cost-effectiveness analyses using data from trials which exaggerate their impact and do not include several categories of 'high risk'. This study aimed to assess the real cost-effectiveness of DES using prospectively collected outcome data from consecutive patients in the immediate pre-DES era.

A prospective database on all percutaneous coronary interventions (PCI) performed by one operator in the two years prior to DES introduction (July 2000-June 2002) was used in which 12-month follow-up was complete in 96%. In 490 patients, 510 PCI were undertaken on 650 lesions (298 'high risk') using 686 stents. Angiography-proven clinical restenosis occurred in 31 lesions (5%) in 27 patients (12 focal, 19 diffuse; 11 treated with CABG, 14 with repeat PCI [4 re-restenosed-3 re-rePCI, 1 CABG] and 2 treated medically) with 2 deaths (both post-CABG). If all 'high risk' lesions had been treated with DES (assuming 0% clinical restenosis) then 22 lesions in 18 patients would not have restenosed avoiding 8 CABG and 13 re-PCI. Assuming A 5186 dollars cost for re PCI and A 18,496 dollars for CABG, DES will only be cost neutral for 'high risk' lesions when the premium for DES reduces to 617 dollars (currently 1500 dollars) and for all lesions at 452 dollars.

Current strategies for use of DES are not cost-effective. DES should be reserved for restenosis until the price comes down.