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The article presents a review of two randomised controlled trials for the management of mild-to-moderate chronic stable coronary artery disease. Results of the studies have triggered a debate about whether an initial strategy of revascularization or a conservative approach with drugs is most effective. Among the three main treatment goals in patients with chronic stable coronary artery disease is relief of symptoms and ischaemia. A summary of the major randomised controlled trials is also presented.

Context Right ventricular involvement in acute myocardial infarction and cardiogenic shock has received little attention by clinicians and researchers, although its pathophysiology, clinical presentation, and natural history are distinctly different from those of left ventricular infarction and associated cardiogenic shock. Right ventricular shock has important therapeutic implications for the management of patients, which need to be recognised. Starting point Investigators at the SHOCK Registry Alice Jacobs and colleagues, J Am Coll Cardiol 2003; 341: 1273--79) evaluated 49 patients with cardiogenic shock predominantly due to right ventricular infarction and compared them with 884 patients with cardiogenic shock and predominantly left ventricular failure. Perhaps surprisingly, these investigators found that the in-hospital mortality of patients with right ventricular shock was not significantly lower than that of patients with left ventricular shock (53% vs 61%, p=0.296), despite the fact that patients with right ventricular shock were younger, with a lower prevalance of previous infarctions, fewer anterior infarct locations, and less multivessel disease. There was a shorter median time between index infarction and diagnosis of shock in patients with right ventricular shock. In multivariate analysis, right ventricular shock was not an independent predictor of lower in-hospital mortality. Where next? The unexpectedly high mortality of patients with cardiogenic shock due to predominantly right ventricular infarction challenges the general notion that right ventricular involvement in myocardial infarction has only little relevance for patient's outcome. Therefore, more attention should be given to the detection of right ventricular involvement in acute myocardial infarction and particularly in cardiogenic shock. [ABSTRACT FROM AUTHOR]

This article presents the results of an 18 month study on the cost-effectiveness of drug-eluting stents in patients at high or low risk of major cardiac events. To assess the value of these medical devices, the authors looked at cost of the procedure and the rate of follow-up events which were usually vessel revascularisations avoided by placement of the stents. The study found that overall costs were higher for patients with drug-eluting stents over those with bare metal stents due to the higher price of the drug-eluting stent. If used in all patients, the drug-eluting stents would not be good value for the money. They are cost effective in patients who need small vessel or bypass graft stenting but not in those who need larger vessel stenting.

This article presents a meta-analysis of outcomes associated with drug-eluting and bare-metal stents. The study sought to see if there was a difference in outcomes between the sirolimus-eluting stents, the paclitaxel-eluting stents and the bare-metal stents. The study found that mortality was similar in all three groups. In comparing sirolimus-eluting stents with bare-metal, the drug-eluting stents were associated with the lowest rate of myocardial infarction. The risk of late definite stent thrombosis was increased with the paclitaxel-eluting stents. The reduction in target lesion revascularisation was more pronounced with the sirolimus-eluting stents which leads the authors to conclude that sirolimus-eluting stents seem to be clinically better than the other two.

Summary Background No prospective trial-based data are available for incremental cost-effectiveness of drug-eluting stents (DES) compared with bare-metal stents (BMS) in unselected patients, as treated in everyday practice. Methods The Basel stent cost-effectiveness trial (BASKET) included 826 consecutive patients treated with angioplasty and stenting for 1281 de-novo lesions, irrespective of indication for angioplasty. Patients were randomised to one of two DES (Cypher, n=264; Taxus, n=281) or to a cobalt-chromium-based BMS (Vision, n=281) and followed up for 6 months for occurrence of major adverse cardiac events and costs. Analysis was by intention-to-treat. The primary endpoint was cost-effectiveness after 6 months, with effectiveness defined as reduction of major adverse cardiac events. Findings Cardiac death, myocardial infarction, or target vessel revascularisation occurred in 39 of 544 (7·2%) patients with DES and 34 of 280 (12·1%) with BMS (odds ratio 0·56, 95% CI 0·35-0·91; p=0·02), without significant differences between the two DES. Total costs at 6 months were higher with DES (mean &z.euro;10 544, SD 6849) than with BMS (&z.euro;9639, 9067; p<0·0001); higher stent costs of DES were not compensated for by lower follow-up costs. Incremental cost-effectiveness ratio of DES compared with BMS to avoid one major event was &z.euro;18 311, and costs per quality-adjusted life-year gained were more than &z.euro;50 000. Subgroup analyses showed that DES were more cost-effective for elderly patients in specific high-risk groups. Interpretation In a real-world setting, use of DES in all patients is less cost effective than in studies with selected patients. Use of these stents could be restricted to patients in high-risk groups. [ABSTRACT FROM AUTHOR]