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VIEWPOINT

Paradigm shifts in cardiovascular medicine

David R. Holmes, Jr, MD, FACC^*,*, Brian G. Firth, MD, PhD, FACC and Douglas L. Wood, MD, FACC^*

^* Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
Cordis Corporation, Warren, New Jersey, USA

Manuscript received March 7, 2003; revised manuscript received August 5, 2003, accepted August 25, 2003.

^* Reprint requests and correspondence: Dr. David R. Holmes, Jr, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA.
holmes.david{at}mayo.edu

Cardiovascular medicine is changing rapidly with the development, testing, and introduction of new diagnostic and therapeutic methods. New interventional techniques such as the use of drug-eluting stents have important implications for the care of individual patients and the delivery and economics of health care in general. Drug-eluting stents have been shown to improve outcomes among patients undergoing percutaneous coronary intervention by significantly reducing restenosis rates. Two randomized trials have documented that per 100 patients treated with the sirolimus drug-eluting stent, 12.5 to 13.6 patients avoided the need for subsequent target lesion revascularization, when compared with patients treated with conventional stents. The economic effect of the introduction of these stents, which are projected to be two to three times as expensive as conventional stents, is complex and depends on which segment of health care is considered. These stents will be favorably received by patients, physicians, employers, and society as well as payers. However, hospitals may be adversely affected by having increased procedural costs for the stents, along with fewer procedures for evaluation and treatment of restenosis and probably decreased surgical volumes. Drug-eluting stents are only the first of many new technologic advances that will affect cardiovascular care. These procedures have many features in common, including: 1) replacement of major surgical procedures with less invasive approaches; and 2) redistribution of costs, with a decrease in hospital profits but potentially lower costs of health care delivery for society as a whole.

Abbreviations and Acronyms   ARTS = Arterial Revascularization Therapy Study   CABG = coronary artery bypass graft surgery   DRG = diagnosis-related group   FDA = Food and Drug Administration   ICD-9 = International Classification of Diseases- Ninth Revision   PCI = percutaneous coronary intervention   RAVEL = Randomized Study with the Sirolimus-Eluting Bx VELOCITY Stent trial   SIRIUS = Sirolimus-Eluting Bx VELOCITY Stent trial

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