Drug-eluting stents.

In their recent systematic review, Suzanne Ligthart and associates compared analyses of the cost-effectiveness of drug-eluting stents. They found that in most studies in which an incremental cost-effectiveness ratio greater than $50 000 per quality-adjusted life-year was calculated the study authors recommended against the widespread use of drug-eluting stents. However, we believe that previously published cost analyses of drug-eluting stents, including those mentioned by Ligthart and associates, may have failed to consider the potential costs of lifetime therapy with clopidogrel. Recent evidence suggests that cessation of clopidogrel therapy in patients with drug-eluting stents can lead to severe adverse outcomes such as in-stent thrombosis and may pose an increased mortality risk. As a result, the duration of clopidogrel therapy in these patients has become controversial, leading most physicians to treat these patients indefinitely. A cost analysis of 1 year of clopidogrel therapy in the PCI-CURE and CREDO trials showed diminishing returns after 4 weeks of therapy and that an expenditure ranging from $70 000 to $350 000 was required to avoid a single myocardial infarction. Given that the only proven benefit of drug-eluting stents over conventional bare-metal stents is the reduction in target vessel restenosis, we feel that the additional cost of lifetime clopidogrel therapy makes drug-eluting stents even less desirable. In a publicly funded health care system with limited resources, such as ours, interventions that provide marginal benefit at a high cost should be carefully scrutinized.