Drug eluting stents are not effective for treating vulnerable plaque. There is no evidence they address the underlying disease. Widespread use for vulnerable plaque would be extremely costly due to the large number of potential patients and high per-stent costs. Vulnerable plaque is a systemic, diffuse problem that requires a treatment approach beyond local therapies like stents. Developing global therapies for the entire coronary tree is a better strategy than using stents to treat individual lesions.

1. Drug Eluting Stents
The Wrong therapy
for Vulnerable Plaque
RS Schwartz
Minneapolis Heart Institute

2. A 3-Part Argument
There are no data yet
VP Detection and
Economics
The Strategy is wrong

3. FACT
Drug Eluting stents
appear to form a
healthy neointima
The restenosis rate
may be 8-10%

4. FACT
Long term results are
pending
We have no data for
mild disease or
Vulnerable lesions

5. Argument #1
There is simply no
evidence that the drug
eluting stent will fix the
vulnerable plaque
problem.

6. FACT
Drug Eluting stents
will initially cost about
$3,000 each.

7. FACT
Sensitivity and
Specificity for Detection
are unknown but will
likely be poor
??40%- 50%

8. FACT
If a typical patient
has 3-4 such plaques, a
single session will cost
$12,000 in stents alone

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. Argument #2
Stenting every
vulnerable plaque will
break the National
Budget.
Which Lesions to
stent and which to
ignore?

11. Fact
Vulnerable Plaque
is a multifocal and
possibly diffuse
disease

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. Spagnoli et al
3 Groups, Autopsy pts
Acute MI
Old MI
No CAD
Cell Suspensions of all
3 coronary arteries

14. Spagnoli et al
Flow Cytometry
Lymphocytes
SMC
CD3/CD68

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. 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. Fact
We just spent 12
years developing
Drug Eluting Stents
as a LOCAL therapy

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. Rhetoric
Treating a systemic
disease with a local
therapy makes no
sense.

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. “Shoot’em all boys, the
Devil will sort them
out…”
Clint Eastwood, 1972

22. Strategy
Rearrange the
cellular mileu of the
entire coronary tree.
Treat the disease, not
the lesions.

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. Axiom
In any debate,
present your case
simply and cogently.
Then personally
savage your opponent.

25. Positions
Photographs
Motherhood
Lennox Hill Hosp
Iranian