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Schwartz debate aha 2002


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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