[HSF] Stent-vs-surgery debate heats up again

[A]

Thanks for these good references. Please keep the HSF posted. 

Ahmed

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of M. A. Quader, MD
Sent: Friday, March 23, 2007 12:22 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Stent-vs-surgery debate heats up again

There is more to the debate,longterm outcome information on DES vs. BMS was
published in NEJM,, March 8 issue of 2007. Five original articles, two editorials
and one FDA perspective. Bottom line, if DES are used out side of study patients
(single vessel, simple lesions) there is an incremental mortality of 0.5% per year
compared to BMS. I have never seen NEJM ever take an issue to this extent ever
before, we must read that issue and share the information with cardiologists and
family physicians.

Thanks.
Mo

>
> Stent-vs-surgery debate heats up again
>
> Mar 22, 2007Sue Hughes
>
> London and York, UK - Three new studies, published in the March 24, 2007 issue of
> BMJ, have questioned the clinical and cost effectiveness of stenting and suggest
> that surgery may be the better option for many patients. In an accompanying
> editorial [1], cardiac surgeon Prof David Taggart (University of Oxford, UK) says
> these studies "raise key issues not only about the decision-making process for
> intervention in the individual patient but also how to obtain maximum value from
> limited health-service resources." In an interview with heartwire, Taggart claimed
> that many patients are never even informed about the possible benefits of surgery,
> as the decision process is handled by an interventional cardiologist. Taggart is
> calling for a change in the way these patients are managed, with a
> multidisciplinary team being involved in the decision as to whether to treat with
> stent or surgery.  Commenting on these papers for heartwire, interventionalist Dr
> Robert Harrington (Duke University, Durham, NC) said these studies and editorial
> demonstrate a growing concern among cardiac surgeons that their livelihood is
> being threatened by PCI, which has evolved over recent years to be the dominant
> form of CAD revascularization. But he added that the call for interdisciplinary
> teams to evaluate the revascularization options with patients was an interesting
> idea and one that might be beneficial for patients.
>
>
> LAD single-vessel-disease meta-analysis
> The first two papers look at patients with single-vessel disease of the left
> anterior descending (LAD) coronary artery [2,3]. The authors, led by Dr Omer Aziz
> (Imperial College London, UK), conducted a meta-analysis of 12 studies comparing
> the best percutaneous intervention (transluminal coronary artery stenting) with
> the least invasive surgical intervention (minimally invasive direct coronary
> artery bypass with left internal thoracic artery) in such patients. Results showed
> that patients who received stents had a higher rate of recurrence of angina, more
> major adverse coronary and cerebral events, and more repeat revascularizations
> than those who underwent surgery. But there was no significant difference in MI,
> stroke, or mortality at maximum follow-up between interventions. The researchers
> conclude that the findings suggest that minimally invasive direct coronary artery
> bypass produces a more definitive revascularization in the mid term in these
> patients.
>
>
> Surgery cost-effective in long-term
> The second paper, by the same group, looked at the cost-effectiveness of these
> procedures, again in patients with single-vessel disease of the LAD. Results
> showed that stenting was more effective and less costly than bypass surgery in the
> first two years, but in the third year, bypass surgery, while still more
> expensive, became marginally more effective, although not cost-effective at this
> point. However, by 10 years, the authors say, surgery "is probably
> cost-effective," with a cost of £6274.02 per quality-adjusted life year (QALY).
> They conclude that minimally invasive left internal thoracic artery bypass is more
> effective than stenting in the long term, justifying its initial additional cost,
> but these findings do not take into account the effect of drug-eluting stents, for
> which data on long-term effectiveness are awaited The third paper deals with a
> different group of patients—those with multivessel disease [4]. The authors, led
> by SC Griffin (University of York, UK), conducted an observational study comparing
> cost-effectiveness of CABG, stenting, or medical management in patients rated as
> appropriate for revascularization. Results showed that CABG seemed cost-effective
> but stenting did not. "Cost-effectiveness analysis based on observational data
> suggests that the clinical benefit of percutaneous coronary intervention may not
> be sufficient to justify its cost," the researchers conclude.
>
>
> An interventionalist responds
> Responding to some of these issues for heartwire, interventional cardiologist Dr
> David Moliterno (University of Kentucky, Lexington) described the meta-analysis by
> Aziz and colleagues as "provocative," but he pointed out that even with data
> combined from several studies their data set remains too small to provide new
> insight or definitive guidance for clinical practice. Moliterno said: "It is well
> established that percutaneous revascularization and bypass surgery result in
> similar rates of death and myocardial infarction at long-term follow-up. Yet if
> the results of the present meta-analysis were extended to 1000 surgically treated
> patients, 17 more deaths and 10 more MIs would occur at maximum follow-up than if
> the patients had undergone stent placement. In contrast, 97 repeat
> revascularizations would be avoided with bypass surgery. In this study, bare-metal
> stents were used, but the new drug-eluting stents markedly reduce the rate of
> repeat revascularizations and therefore could attenuate this benefit of surgery."
> He added: "Fortunately, large-scale, prospective studies are ongoing with the
> SYNTEX and FREEDOM trials, together randomizing more than 4000 patients to
> multivessel bypass surgery vs drug-eluting-stent placement."
>
>
> A moving target?
> But Taggart argues that this is simply moving the goalposts. "There have been
> hosts of studies showing surgery gives better results than stenting over the past
> 20 years, but interventional cardiologists keep on moving the target. When surgery
> was shown to be better than balloon angioplasty, they said, "Wait for the stent
> studies,' and now they are saying, 'Wait for the drug-eluting-stent studies.' " He
> also believes that the benefit of surgery has been underestimated in most studies,
> as patients with more severe disease were excluded. "Most studies comparing stents
> and surgery have enrolled patients with minimal disease, and a survival benefit is
> not going to show up in these patients. But these results have been rolled out to
> justify using stents in all patients. This is a complete distortion of the
> evidence," he commented to heartwire  Taggart admits that, conceptually, stenting
> is obviously a popular option. "If you can achieve the same results without having
> to open the chest, of course this will be appealing. But the result is often not
> the same. And there is enormous pressure from the stent industry, which inevitably
> influences the situation."  He points out that there is much more evidence in
> favor of surgery in patients with multivessel disease, with a survival benefit
> having been shown in this group, but there is still an increasing tendency for
> these patients to get stents. Taggart believes the fact that interventional
> cardiologists alone make the decision of whether stents or surgery should be used
> is the stumbling block here. "A significant number of patients don't even know
> that surgery is an option. Patients need to be given all the information on the
> options before the decision as to which way to go is made. "Yes, there is the
> supermarket convenience of inserting a stent while the patient is there in the
> cath lab rather than having to schedule another procedure time, but this is not a
> trivial decision. It is not reasonable for this decision to be made in a couple of
> minutes when the patent is lying on the cath-lab table. The different options need
> to be explained thoroughly, with input from both interventionalists and surgeons."
>  Taggart says some lesions can be stented there and then in the cath lab and no
> one will argue—for example, single-vessel disease that is not proximal and for
> which stenting will not block a side branch. "But for more complicated
> single-vessel lesions and all multivessel disease, the treatment procedure should
> be separated from the diagnostic procedure and not undertaken until the patient
> has been informed of all the options," he concludes.
>
>
> Stop the "mine-is-better-than-yours" mentality
> Harrington comments that Taggart has some interesting ideas but that too much
> effort (and marketing money) is spent on the "mine-is-better-than-yours" mentality
> and that instead all parties should work together to address the questions that
> will truly allow better healthcare. "Care for patients with obstructive CAD should
> be evidence based, and PCI and CABG should be thought of as complementary
> procedures with benefits (and risks) for different categories of patients based on
> CAD anatomy, LV function, other comorbid conditions, and patient values and
> preferences," he concludes.
>
>
>
> Sources
>
>
> Taggart DP. Coronary revascularization surgery is effective on clinical and
> economic grounds, but stenting does not seem to be cost effective. BMJ 2007;
> 334:593-594.   Aziz O, Rao C, Panesar SS et al. Meta-analysis of minimally
> invasive internal thoracic artery bypass versus percutaneous revascularisation for
> isolated lesions of the left anterior descending artery. BMJ 2007; 334:617-621.
> Rao C, Aziz O, Panesar SS et al. Cost effectiveness analysis of minimally invasive
> internal thoracic artery bypass versus percutaneous revascularisation for isolated
> lesions of the left anterior descending artery. BMJ 2007; 334:621-624.   Griffin
> SC, Barber JA, Manca A. Cost effectiveness of clinically appropriate decisions on
> alternative treatments for angina pectoris: prospective observational study. BMJ
> 2007; 334:624-628.
>
>
>
>
>
>
>
>
> Edward P. Raines, M.D., J.D.
> BryanLGH Cardiothoracic Surgery
> BryanLGH Medical Center East
> 1600 South 48th Str.
> Lincoln, Nebraska 68506
> Office: 402-481-8430
> Cell: 402-730-9242
> Fax: 402-481-8429
>
>
>
>
>
>
> AOL now offers free email to everyone. Find out more about what's free from AOL at
> AOL.com.  Attached Message
> From:sendArticles at theheart.org
> To:dukeB60 at aol.com
> Subject:{Disarmed} Stent-vs-surgery debate heats up again
> Date:Thu, 22 Mar 2007 8:46 PM
>
> At the request of Clyde Meckel (drmeckel at bhi-1.com), you are being sent a link to
> an article from theheart.org, the website for cardiovascular health professionals.
>
> Message from Clyde Meckel : NAAAAAAH
>
>
> Stent-vs-surgery debate heats up again
>
> Mar 22, 2007Sue Hughes
>
> London and York, UK - Three new studies, published in the March 24, 2007 issue of
> BMJ, have questioned the clinical and cost effectiveness of stenting and suggest
> that surgery may be the better option for many patients. In an accompanying
> editorial [1], cardiac surgeon Prof David Taggart (University of Oxford, UK) says
> these studies "raise key issues not only about the decision-making process for
> intervention in the individual patient but also how to obtain maximum value from
> limited health-service resources." In an interview with heartwire, Taggart claimed
> that many patients are never even informed about the possible benefits of surgery,
> as the decision process is handled by an interventional cardiologist. Taggart is
> calling for a change in the way these patients are managed, with a
> multidisciplinary team being involved in the decision as to whether to treat with
> stent or surgery.  Commenting on these papers for heartwire, interventionalist Dr
> Robert Harrington (Duke University, Durham, NC) said these studies and editorial
> demonstrate a growing concern among cardiac surgeons that their livelihood is
> being threatened by PCI, which has evolved over recent years to be the dominant
> form of CAD revascularization. But he added that the call for interdisciplinary
> teams to evaluate the revascularization options with patients was an interesting
> idea and one that might be beneficial for patients.
>
>
> LAD single-vessel-disease meta-analysis
> The first two papers look at patients with single-vessel disease of the left
> anterior descending (LAD) coronary artery [2,3]. The authors, led by Dr Omer Aziz
> (Imperial College London, UK), conducted a meta-analysis of 12 studies comparing
> the best percutaneous intervention (transluminal coronary artery stenting) with
> the least invasive surgical intervention (minimally invasive direct coronary
> artery bypass with left internal thoracic artery) in such patients. Results showed
> that patients who received stents had a higher rate of recurrence of angina, more
> major adverse coronary and cerebral events, and more repeat revascularizations
> than those who underwent surgery. But there was no significant difference in MI,
> stroke, or mortality at maximum follow-up between interventions. The researchers
> conclude that the findings suggest that minimally invasive direct coronary artery
> bypass produces a more definitive revascularization in the mid term in these
> patients.
>
>
> Surgery cost-effective in long-term
> The second paper, by the same group, looked at the cost-effectiveness of these
> procedures, again in patients with single-vessel disease of the LAD. Results
> showed that stenting was more effective and less costly than bypass surgery in the
> first two years, but in the third year, bypass surgery, while still more
> expensive, became marginally more effective, although not cost-effective at this
> point. However, by 10 years, the authors say, surgery "is probably
> cost-effective," with a cost of £6274.02 per quality-adjusted life year (QALY).
> They conclude that minimally invasive left internal thoracic artery bypass is more
> effective than stenting in the long term, justifying its initial additional cost,
> but these findings do not take into account the effect of drug-eluting stents, for
> which data on long-term effectiveness are awaited The third paper deals with a
> different group of patients—those with multivessel disease [4]. The authors, led
> by SC Griffin (University of York, UK), conducted an observational study comparing
> cost-effectiveness of CABG, stenting, or medical management in patients rated as
> appropriate for revascularization. Results showed that CABG seemed cost-effective
> but stenting did not. "Cost-effectiveness analysis based on observational data
> suggests that the clinical benefit of percutaneous coronary intervention may not
> be sufficient to justify its cost," the researchers conclude.
>
>
> An interventionalist responds
> Responding to some of these issues for heartwire, interventional cardiologist Dr
> David Moliterno (University of Kentucky, Lexington) described the meta-analysis by
> Aziz and colleagues as "provocative," but he pointed out that even with data
> combined from several studies their data set remains too small to provide new
> insight or definitive guidance for clinical practice. Moliterno said: "It is well
> established that percutaneous revascularization and bypass surgery result in
> similar rates of death and myocardial infarction at long-term follow-up. Yet if
> the results of the present meta-analysis were extended to 1000 surgically treated
> patients, 17 more deaths and 10 more MIs would occur at maximum follow-up than if
> the patients had undergone stent placement. In contrast, 97 repeat
> revascularizations would be avoided with bypass surgery. In this study, bare-metal
> stents were used, but the new drug-eluting stents markedly reduce the rate of
> repeat revascularizations and therefore could attenuate this benefit of surgery."
> He added: "Fortunately, large-scale, prospective studies are ongoing with the
> SYNTEX and FREEDOM trials, together randomizing more than 4000 patients to
> multivessel bypass surgery vs drug-eluting-stent placement."
>
>
> A moving target?
> But Taggart argues that this is simply moving the goalposts. "There have been
> hosts of studies showing surgery gives better results than stenting over the past
> 20 years, but interventional cardiologists keep on moving the target. When surgery
> was shown to be better than balloon angioplasty, they said, "Wait for the stent
> studies,' and now they are saying, 'Wait for the drug-eluting-stent studies.' " He
> also believes that the benefit of surgery has been underestimated in most studies,
> as patients with more severe disease were excluded. "Most studies comparing stents
> and surgery have enrolled patients with minimal disease, and a survival benefit is
> not going to show up in these patients. But these results have been rolled out to
> justify using stents in all patients. This is a complete distortion of the
> evidence," he commented to heartwire  Taggart admits that, conceptually, stenting
> is obviously a popular option. "If you can achieve the same results without having
> to open the chest, of course this will be appealing. But the result is often not
> the same. And there is enormous pressure from the stent industry, which inevitably
> influences the situation."  He points out that there is much more evidence in
> favor of surgery in patients with multivessel disease, with a survival benefit
> having been shown in this group, but there is still an increasing tendency for
> these patients to get stents. Taggart believes the fact that interventional
> cardiologists alone make the decision of whether stents or surgery 
should be used
> is the stumbling block here. "A significant number of patients don't even know
> that surgery is an option. Patients need to be given all the information on the
> options before the decision as to which way to go is made. "Yes, there is the
> supermarket convenience of inserting a stent while the patient is there in the
> cath lab rather than having to schedule another procedure time, but this is not a
> trivial decision. It is not reasonable for this decision to be made in a couple of
> minutes when the patent is lying on the cath-lab table. The different options need
> to be explained thoroughly, with input from both interventionalists and surgeons."
>  Taggart says some lesions can be stented there and then in the cath lab and no
> one will argue—for example, single-vessel disease that is not proximal and for
> which stenting will not block a side branch. "But for more complicated
> single-vessel lesions and all multivessel disease, the treatment procedure should
> be separated from the diagnostic procedure and not undertaken until the patient
> has been informed of all the options," he concludes.
>
>
> Stop the "mine-is-better-than-yours" mentality
> Harrington comments that Taggart has some interesting ideas but that too much
> effort (and marketing money) is spent on the "mine-is-better-than-yours" mentality
> and that instead all parties should work together to address the questions that
> will truly allow better healthcare. "Care for patients with obstructive CAD should
> be evidence based, and PCI and CABG should be thought of as complementary
> procedures with benefits (and risks) for different categories of patients based on
> CAD anatomy, LV function, other comorbid conditions, and patient values and
> preferences," he concludes.
>
>
>
> Sources
>
>
> Taggart DP. Coronary revascularization surgery is effective on clinical and
> economic grounds, but stenting does not seem to be cost effective. BMJ 2007;
> 334:593-594.   Aziz O, Rao C, Panesar SS et al. Meta-analysis of minimally
> invasive internal thoracic artery bypass versus percutaneous revascularisation for
> isolated lesions of the left anterior descending artery. BMJ 2007; 334:617-621.
> Rao C, Aziz O, Panesar SS et al. Cost effectiveness analysis of minimally invasive
> internal thoracic artery bypass versus percutaneous revascularisation for isolated
> lesions of the left anterior descending artery. BMJ 2007; 334:621-624.   Griffin
> SC, Barber JA, Manca A. Cost effectiveness of clinically appropriate decisions on
> alternative treatments for angina pectoris: prospective observational study. BMJ
> 2007; 334:624-628.
>
>
>
>
>
>
> Related links
>
>
> Stent or operate? New York Times revisits the age-old stenting vs surgery
> conundrum  [Other News > MediaPulse; Feb 26, 2007]
>
> Stenting vs surgery: The surgeons' view
> [HeartWire > Other News; Sep 05, 2006]
>
> Three-year survival better with CABG than stenting for most multivessel CAD in
> registry analysis  [HeartWire > Other News; May 25, 2005]
>
>
>
>
>
>
> Access to theheart.org is free, and is available only to healthcare professionals,
> media representatives, and medical librarians. To register as a user of
> theheart.org, click: http://www.theheart.org/
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