Drug-eluting coronary stents: faith and hope, but no charity.

Commentary All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association. J udging from the large number of publications on the cost-effectiveness of drug-eluting coronary stents, there is an emerging international consensus that the price tag for the 2 commercially available drug-eluting stents is excessive (approximately $1500 to $3000 per stent in Canada). Why is the price so high? What motivates cardiac centres around the world to continue to buy them in large volumes? The answers to these questions are, in large part, rooted in the very history of the percutaneous coronary intervention (PCI) procedure and in the funding model for the development of new technologies that exists in most of the developed world. Despite the phenomenal international acceptance of PCI over the past 3 decades, strong scientific support for PCI usage patterns has been elusive. Indeed, the interventional community is often accused of making decisions based on faith more than on fact. Even confirmation of PCI use in selected high-risk patients with acute coronary syndromes was a relatively recent development. Since the very beginning, restenosis and the associated need for revascularization have been responsible for tainting PCI performance in clinical trials. 2 In 1994, bare-metal stents were introduced to eliminate elastic recoil and stabilize plaque disarray after balloon interventions. These devices lowered the need for repeat interventions in target vessels from 25% to 13% 3 — a significant but only partial success in the war on restenosis. The introduction of drug-eluting stents in 2002 in Europe and Canada and in 2003 in the United States further lowered the need for revascularization in target vessels to the more comfortable rate of 4%. Health care professionals who lived through the long restenosis " pandemic " would find it difficult to reject this apparent cure for restenosis, despite the imposing price tag for drug-eluting stents. Most interventional cardiologists possess the abiding hope that an end to the problem of restenosis will open a new era, one in which patients with more complex and diffuse coronary artery disease will be successfully treated with PCI. In this issue of CMAJ, 2 articles provide important insights into the use of drug-eluting stents. In the first, Grilli and coauthors report on the use of drug-eluting stents and corresponding PCI and cardiac surgery rates in public and private hospitals in the Emilia-Romagna region of Italy. 5 They …