Tuesday, August 29, 2006

New Lessons for DES patients

When Drug Eluting Stents (DES) first came to the world, it was embraced by one and all (except a certain pathologist - Virmani), that it will revolutionise PCI and management of CAD. DES promised to defeat restenosis, and "statins" will defeat atherosclerosis especially those minor, non-significant lesions.

In 2002-2004 we were implanting almost 80-90% of DES in our PCI patients. We saw vey few restenosis. It might have been one of the reasons for a reduction in PCI rates, maybe the loss of the 15-20% patients who use to come back with restenosis for repeat angioplasty.

Dr Virmani began a crusade (almost single-handedly) in 2004, telling us that DES had severe vessel wall reactions, having examined about 40 necropsy of patients who died post DES. Last year, we saw an important paper, the Late Basket trial which warned us of late stent thrombosis. As clinicians, we were also seeing the occasional patient who has stent thrombosis, months or years after the DES implantation. Late stent thrombosis, is now a well recognised, dreaded late complication of DES. We have also learn that LST-DES occurs particularly in two clinical situations. Firstly, the premature discontinuation of plavix, and secondly chronic renal failure.

Recently, another paper came out from the excellent PCI center, the Mid-America Heart Institute, that 1 in 7 of our patients do not take their plavix, though prescribed, and in those with previous heart attacks, the mortality is ten times higher than the non infarct DES patient. This is certainly very worrying.

As I said, at my talk to the MOs in the BMS National Cardiovascular workshop, on 19th August, do not callously stop plavix in patients who had received a DES. Please take the trouble to contact the cardiologist in charge. Well I think that we will learn more about LST-DES soon. I have my own theory. Will post about this later.

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