Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Schwartz debate aha 2002

64 views

Published on

SHAPE Society

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Schwartz debate aha 2002

  1. 1. Drug Eluting Stents The Wrong therapy for Vulnerable Plaque RS Schwartz Minneapolis Heart Institute
  2. 2. A 3-Part Argument There are no data yet VP Detection and Economics The Strategy is wrong
  3. 3. FACT Drug Eluting stents appear to form a healthy neointima The restenosis rate may be 8-10%
  4. 4. FACT Long term results are pending We have no data for mild disease or Vulnerable lesions
  5. 5. Argument #1 There is simply no evidence that the drug eluting stent will fix the vulnerable plaque problem.
  6. 6. FACT Drug Eluting stents will initially cost about $3,000 each.
  7. 7. FACT Sensitivity and Specificity for Detection are unknown but will likely be poor ??40%- 50%
  8. 8. FACT If a typical patient has 3-4 such plaques, a single session will cost $12,000 in stents alone
  9. 9. FACT Including all asymptomatic patients, there may be 2,000,000 candidates. At $12,000 each, this will be $24,000,000,000 in stents alone
  10. 10. Argument #2 Stenting every vulnerable plaque will break the National Budget. Which Lesions to stent and which to ignore?
  11. 11. Fact Vulnerable Plaque is a multifocal and possibly diffuse disease
  12. 12. Fact Vulnerable Plaque is a systemic disease Multicentric inflammation in epicardial coronary arteries of patients dying of acute myocardial infarction. Spagnoli LG, Bonanno E, Mauriello A, Palmieri G, Partenzi A, Sangiorgi G, Crea F. J Am Coll Cardiol 2002 Nov 6;40(9):1579-88
  13. 13. Spagnoli et al 3 Groups, Autopsy pts Acute MI Old MI No CAD Cell Suspensions of all 3 coronary arteries
  14. 14. Spagnoli et al Flow Cytometry Lymphocytes SMC CD3/CD68
  15. 15. Spagnoli et al Results Diffuse lymphoctye activation in all 3 arteries of Acute MI patients 11 5.6 0 3 6 9 12 Percent Acute MI Old MI No CAD
  16. 16. Patient 4, Stable, NZPatient 4, Stable, NZ MaxT Difference Map of RCAMaxT Difference Map of RCA 0 .05 .1 .15 .2 .25 MaxTdiff Distal MID Prox
  17. 17. Fact We just spent 12 years developing Drug Eluting Stents as a LOCAL therapy
  18. 18. Fact Rox’s own data argues against stents The 1 year recurrent MACE in Acute Coronary Syndromes with PCI may be as high as 20%
  19. 19. Rhetoric Treating a systemic disease with a local therapy makes no sense.
  20. 20. Argument #3 It is folly to treat a diffuse problem with a focal therapy. We must instead develop simple therapies for the entire coronary tree.
  21. 21. “Shoot’em all boys, the Devil will sort them out…” Clint Eastwood, 1972
  22. 22. Strategy Rearrange the cellular mileu of the entire coronary tree. Treat the disease, not the lesions.
  23. 23. Summary 1. No efficacy data in mild/minimal disease 2. We can’t afford to treat with Drug Eluting Stents 3. It is folly to treat a diffuse problem with a focal therapy.
  24. 24. Axiom In any debate, present your case simply and cogently. Then personally savage your opponent.
  25. 25. Positions Photographs Motherhood Lennox Hill Hosp Iranian

×