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Previous Volume 347:1285 October 17, 2002 Number 16 Next

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To the Editor: The results of the RAVEL study (Randomized Study with the Sirolimus-Coated Bx Velocity Balloon-Expandable Stent in the Treatment of Patients with de Novo Native Coronary Artery Lesions) (June 6 issue)¹ are promising and bring to light the ethical and financial dilemma that is likely to surface once drug-eluting stents are approved for general use. The projected cost of each stent is likely to be about $3,200. Of course, from a financial and societal standpoint, it will not be possible to deploy drug-eluting stents in every case of percutaneous coronary-stent intervention. From an individual patient's standpoint, a drug-eluting stent may be a panacea for a given treated lesion. How does one arrive at a balance? In what cases should the use of a drug-eluting stent be considered absolutely justified and maybe even crucial? We need to arrive at guidelines to determine the point at which the cost of the device offsets the need for repeated coronary interventions, especially in situations in which the risk of restenosis is high or in which presentation with restenosis will probably result in coronary-artery bypass surgery. For example, in patients with diabetes who have a long diseased segment in a small-caliber, proximal left anterior descending artery, treatment with a drug-eluting stent may make good sense. However, a focal lesion in a large-caliber, distal right posterolateral branch in a nondiabetic, nonsmoking patient may not justify the use of a drug-eluting stent.

Sanjiv Sharma, M.D.
Brijesh Bhambi, M.D.
William Nyitray, M.D.
Bakersfield Heart Hospital
Bakersfield, CA 93301
sanjiv1122{at}yahoo.com

References

1. Morice M-C, Serruys PW, Sousa JE, et al. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 2002;346:1773-1780. [Free Full Text]

To the Editor: Sharma and colleagues raise a crucial issue. The cost of drug-eluting stents is indeed very high. However, this high initial cost is expected to be significantly offset by the reduced rate of recurrent events and the subsequent reduced need for repeated intervention observed in our study at one year among the recipients of sirolimus-eluting stents. The cost-effectiveness analysis that was an objective of the RAVEL trial should provide a clearer picture of the financial aspects of the use of these new devices. As they are increasingly used, the price of these stents is likely to decrease, as is often the case with any new device.

In the meantime, the frustration felt by physicians and their patients in view of the financial dilemma rightfully underlined by Sharma et al. seems more than justified. Nevertheless, the spectacular therapeutic progress brought about by the drug-eluting stents is a reality that cannot be denied.

The following RAVEL investigators were inadvertently omitted in the Appendix to our article: C.R. Costantini, M. de Freitas Santos, S.G. Tarbine, D.A. Zanerttini, and J.L. Lazarte, Clínica Cardiológyca C. Costantini, Curitiba Paraná, Brazil.

Marie-Claude Morice, M.D.
Institut Cardiovasculaire Paris Sud
91300 Massy, France
mc.morice{at}icps.com.fr

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