Pitching the Full Metal Jacket on TV: Have Stent-Manufacturers Crossed the LIne?

Saturday, May 17

Companies that manufacture new "drug-eluting" stents think the solution to the current epidemic of cardiovascular disease is to line Americans' coronary arteries with indestructible titanium.

An editorial in this week's (May 14, 2008) New England Journal of Medicine decries the marketing of stents directly to the American public. New "drug-eluting" stents are the latest solution to a problem frequently encountering by interventional cardiologists: the little metal coils they insert into people's coronary arteries shut down due to scarring. The medicine that the new stents are coated with medcine that suppresses the local immune response, and the stents fail less frequently.

But drug eluting stents don't come cheap: The most popular brand by Johnson and Johnson,Cypher, has a list price of $3,195 per stent (any size or length); several times the cost of the bare metal stents, which have decreased in price due to competition. In the US, an average of 1.7 stents are used per procedure, amounting to $5,400 for just the Cypher stent for every PTCA procedure. An estimated 850,00 stents are done each year on Americans, so do the math!

The New England Journal article is entitled: "DTCA for PTCA: Crossing the Line in Consumer Health Education?" DTCA stands for "direct-to-consumer advertising," and PTCA, or "percutaneous transluminal coronary angioplasty," is medicalese for stenting.

The Journal notes with some alarm that Thanksgiving 2007 heralded the crossing of a new threshold in DTCA. Until then, only drugs were being hawked on TV, on radio and in print media. But last November 22, 2007, while the turkey gravy was still literally congealing in their blood vessels, fans watching the traditional Turkey Day NFL bout between the Cowboys and the Jets were regaled by an unprecedented new ad.

Entitled "Life Wide Open" it depicts a hapless victim of coronary artery disease sitting on the sidelines while his better-vascularized friends are engaging in vigorous activities like fishing, swimming and jogging. The announcer intones: "when your arteries narrow, so does your life" and "it's time to open it." One is left with the impression that that the stent is an unqualified boon to quality of life and survival.

But the real facts, noted in the Journal editorial, are that stents have not been proven superior to good drug and lifestyle therapy in reducing the risk of death from a heart attack. And many countries that lavish fewer resources on expensive cardiac interventions have comparable or better heart survival statistics than we do in the US.

Then there are the side effects, too numerous to catalogue here, but they include sudden death, heart attack, and stroke, and the requirement that stent patients take sometime dangerous blood thinners long after their procedures.

The New England Journal did well to raise the question: do we really need to incite heart disease patients to press their doctors to unnecessarily line their arteries with titanium? What consumers really need is education about how heart disease is not just a matter of rotor-rootering with stents, or fixing with drugs, but rather that it can be addressed with lifestyle, supplements and conservative medical care.