LATEST IN LATE DES STENT THROMBOSIS (LDST) FROM TCT WASHINGTON 2006

Well it looks like the furor over LDST, is much ado about nothing. All the excitement and debate generated by the two papers in Barcelona in September at the WCC/ESC was more hype than fact. That that seems to be the European way. The more practical down to earth cardiologist in Europe obviously feel that there is an issue.

Remember that the Late Basket trial, which first alerted us to the problem (besides the lone crusader-Dr Renu Virmani), is from Switzerland. Then in October, the Americans took over, and boy, did they go to town with it. They had a hotline on LDST, there had a hot debate, and live seesion (to a packed audience in the main arena) with panel discussion including FDA officers, and the two world famous course directors namely Marty Leon and Greg Stone. They re-did the definitions of LDST, with cardiologist from both sides of the Atlantic, and then reanalysed the data so that there was essentially no difference in stent thrombosis, be it bare metal stents or DES. They made a point that even bare metal stents cause deaths.

Even Dr Camezind was loss for words. His only defence was that when he did his meta-analysis, the companies involved (namely Cordis JnJ, and Boston Sc) did not give their full co-operation and their raw data. He was obviously impressed with how the Americans responded to his paper at the WCC Barcelona. Well at the end of all the "hollywood fanfare" what are the facts?

1, It looks like there is a problem of LDST especially in patients with more complex disease, and who were not taking their plavix. 2, Bare metal stents also have this problem and patients did die from bare metal stent restenosis. 3, Taking plavix is very important, maybe for 6 months, a year, or maybe longer. 4, That the previous definition for LDST is not adequate, and we need better definitions. Definite LDST can only be diagnosed if there is clinical and angiographic evidence of stent thrombosis. Otherwise, it may only be probable or possible LDST. 5, That companies manufacturing these stents must be more transparent and forthcoming when asked for data, so that wrong opinions (like from the meta-analysis presented in Barcelona) can be avoided. 6, Stent companies will have to keep monitoring the progress of their patients longterm, watching out for these complications.

Wow, the Americans did do a very thorough job. Yet I think that the problem still remains. We clinicians must recognise that more than half our DES are placed in complex lesions not included in these nice trial data. We have to exercise alot of judgement to see when to use DES and when not to (not only on financial concerns alone). All in all, TCT Washington has tried to quell this fire of LDST, but have they succeeded. I wonder what Dr Renu Virmani and Dr Salim Yusuf, have to say to TCT Washington.