Experts Offer Clarity on Confusion Surrounding Stents

FRIDAY, Feb. 22 (HealthDay News) -- To stent or not to stent? Which type of the artery-opening device is best? When is heart bypass surgery smarter than getting a stent?

These are the questions many heart patients are left asking themselves and their doctors, as dozens of recent high-profile -- and often conflicting -- studies have compared the performance and safety of various types of coronary stents.

But experts say a consensus on the safest and most effective use of the devices is slowly emerging.

For the majority of patients undergoing angioplasty to clear a blocked artery, newer, drug-coated stents are preferred over bare-metal ones, mainly because they reduce the risk of artery re-closure, cardiologists say.

And it may not matter which of the two established brands of drug-eluting stent you get -- Boston Scientific Corp.'s paclitaxel-coated Taxus or Cordis Corp.'s sirolimus-coated Cypher.

"The truth appears to be that whatever differences exist between these two drug-eluting stents are so small that there's not a compelling reason to select one over the other," said Dr. Kirk Garratt, clinical director of interventional cardiovascular research at Lenox Hill Hospital's Heart Vascular Institute, in New York City.

He said that in very special circumstances, a patient may be better suited for one type of drug-coated stent over another, "but for the average patient out there trying to make sense of this, he or she can be comfortable that whatever stent their doctor recommends is going to be a good choice."

The tiny mesh tubes known as coronary stents were first developed in the mid-1980s, and, within a decade, the insertion of bare-metal stents to prop open narrowed vessels had become standard procedure for many patients at risk of heart attack.

However, the rate of artery re-closure, known as restenosis, after the insertion of a bare-metal stent was close to 30 percent. To circumvent that problem, researchers developed drug-eluting stents, which emit medicines that prevent restenosis. A majority of patients who need a stent now receive one of these devices, which cost about $2,000 each, double the price of a bare-metal stent.

In recent years, the Taxus and Cypher drug-eluting stents have dominated the field, and conflicting studies comparing their relative effectiveness appear regularly in major medical journals. A third drug-coated stent, Medtronic's zotarolimus-coated Endeavor, received U.S. Food and Drug Administration approval earlier this month.

But even drug-coated stents aren't perfect. Soon after they gained widespread use, experts began to notice that rates of fatal or nonfatal blood clots were more likely in patients who received a drug-coated stent versus those who did not. This excess clotting risk was confirmed in later trials. For that reason, the FDA recommends that patients who receive drug-eluting stents be placed on dual anti-platelet therapy -- typically Plavix (clopidogrel) and aspirin -- for a year after they receive the device.

But are stents always the best option when arteries narrow or is bypass surgery sometimes a better choice?

In many cases, the answer to that question must still be decided on a case-by-case basis, the experts said. Studies suggest that in cases where only one vessel is blocked, stent placement (during minimally invasive angioplasty) may be a safer and equally effective option.

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