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BACKGROUNDStudies on the cost-effectiveness ratio of drug-eluting stents (DES) are rare. Our objective was to evaluate the results and compare costs (incremental cost-effectiveness ratio – ICER) per restenosis avoided between DES and bare metal stents (BMS) using the propensity score.METHODSTwo hundred and twenty consecutive patients were included in the study, of which 111 were treated with DES and 109 with BMS. The propensity score was used to adjust the effect of the intervention, by means of matching, stratification and weighing.RESULTSMost patients were male (67.7% vs. 66.9%; P = 0.53), with a mean age of 65.9 years. Patients treated with the DES had a higher rate of diabetes (54% vs. 17.4%; P < 0.001), three-vessel disease (18.9% vs. 10.1%; P = 0.029) and poor ventricular function (54.1% vs. 22%; P < 0.0001). The diameter of stents was 2.76 ± 0.35mm vs. 2.91 ± 0.47mm (P = 0.006) and the sum of the lengths of stents was 37.6 ± 23mm vs. 24.8 ± 15.8mm (P < 0.0001). Restenosis was observed on 6.3% vs. 12.8% of the patients (P = 0.099) and in 4.1% vs. 9.8% of the lesions (P = 0.048). There was an incremental cost of R$ 9,500.00 and the ICER was R$ 147,538.00 per restenosis avoided (above the World Health Organization threshold). However, when the propensity score was used, the variables that best classified patients for DES and had a maximum ICER of R$ 4,776.96 were age > 72 years, diabetes and lesions with diameter < 3.2mm and length > 18mm.CONCLUSIONSAlthough DES were not cost-effective in the overall population, the propensity score showed that in elderly patients, diabetics and patients with long lesions or small vessels, the use of DES was cost-effective.

Paciente com angina pos-infarto, associada a lesoes graves, em arterias circunflexa e marginal esquerda. Foi submetida a angioplastia com implante de stents, mas apresentou grave disseccao do tronco de coronaria esquerda (TCE), que se estendeu para o segmento ascendente da aorta, evoluindo com hipotensao, parada cardiorrespiratoria e posterior instabilidade hemodinâmica. Houve resolucao imediata do quadro clinico com implante de stent no TCE.

Descrevem-se dois casos de angioplastia transluminal coronária (ATC) com implante de stents em bifurcação de coronária descendente anterior (DA) com artéria diagonal (DI), destacando-se as técnicas utilizadas. No caso 1, implantou-se na DA um flexistent Gianturco-Roubin (GR) e através de suas hastes, um Palmaz-Schatz (PS) no óstio de DI, com sucesso. O reestudo angiográfico em sete meses mostrou ausência de reestenose. No caso 2, implantou-se metade de um stent PS em DA e outro PS em DI, nesta ordem, também com sucesso. No seguimento clínico de seis meses, paciente encontra-se assintomático. We describe two cases of coronary angioplasty with stents implantation in bifurcational lesion of the left anterior descending artery and the diagonal branch using new techniques successfully performed. Angiographic reestenosis was not present after seven months in one case and the patient was asymptomatic after six months of clinical follow-up in the other.

INTRODUÇÃO: Os estudos sobre a razão de custo-efetividade dos stents farmacológicos (SFs) são escassos. Nosso objetivo foi avaliar os resultados e comparar os custos (razão custo-efetividade incremental - RCEI) por reestenose evitada entre SFs e stents não-farmacológicos (SNFs) utilizando o escore de propensão. MÉTODOS: Incluímos na análise 220 pacientes tratados consecutivamente, dos quais 111 com SFs e 109 com SNFs. O escore de propensão foi usado para ajustar o efeito da intervenção por meio de pareamento, estratificação e ponderação. RESULTADOS: Predominaram pacientes do sexo masculino (67,7% vs. 66,9%; P = 0,53), com média de idade de 65,9 anos. Pacientes tratados com SFs apresentaram maior frequência de diabetes (54% vs. 17,4%; P < 0,001) e doença triarterial (18,9% vs. 10,1%; P = 0,029) e pior função ventricular (54,1% vs. 22%; P < 0,0001). O diâmetro dos stents foi de 2,76 ± 0,35 mm vs. 2,91 ± 0,47 mm (P = 0,006) e a soma do comprimento dos stents foi de 37,6 ± 23 mm vs. 24,8 ± 15,8 mm (P < 0,0001). Reestenose ocorreu em 6,3% vs. 12,8% dos pacientes (P = 0,099) e em 4,1% vs. 9,8% das lesões (P = 0,048). Houve incremento de custo de R$ 9.590,00 e a RCEI foi de R$ 147.538,00 por reestenose evitada (acima do limiar da Organização Mundial da Saúde). Entretanto, utilizando o escore de propensão, as variáveis que melhor classificaram os pacientes para SFs e apresentam RCEI máxima de R$ 4.776,96 foram idade > 72 anos, diabetes e lesões com diâmetro < 3,2 mm e comprimento > 18 mm. CONCLUSÕES: Apesar de os SFs não terem sido custo-efetivos na população em geral, o escore de propensão demonstrou que em idosos, diabéticos e pacientes com lesões longas ou vasos de fino calibre o uso de SFs foi custo-efetivo. BACKGROUND: Studies on the cost-effectiveness ratio of drug-eluting stents (DES) are rare. Our objective was to evaluate the results and compare costs (incremental cost-effectiveness ratio - ICER) per restenosis avoided between DES and bare metal stents (BMS) using the propensity score. METHODS: Two hundred and twenty consecutive patients were included in the study, of which 111 were treated with DES and 109 with BMS. The propensity score was used to adjust the effect of the intervention, by means of matching, stratification and weighing. RESULTS: Most patients were male (67.7% vs. 66.9%; P = 0.53), with a mean age of 65.9 years. Patients treated with the DES had a higher rate of diabetes (54% vs. 17.4%; P < 0.001), three-vessel disease (18.9% vs. 10.1%; P = 0.029) and poor ventricular function (54.1% vs. 22%; P < 0.0001). The diameter of stents was 2.76 ± 0.35 mm vs. 2.91 ± 0.47 mm (P = 0.006) and the sum of the lengths of stents was 37.6 ± 23 mm vs. 24.8 ± 15.8 mm (P < 0.0001). Restenosis was observed on 6.3% vs. 12.8% of the patients (P = 0.099) and in 4.1% vs. 9.8% of the lesions (P = 0.048). There was an incremental cost of R$ 9,500.00 and the ICER was R$ 147,538.00 per restenosis avoided (above the World Health Organization threshold). However, when the propensity score was used, the variables that best classified patients for DES and had a maximum ICER of R$ 4,776.96 were age > 72 years, diabetes and lesions with diameter < 3.2 mm and length > 18 mm. CONCLUSIONS: Although DES were not cost-effective in the overall population, the propensity score showed that in elderly patients, diabetics and patients with long lesions or small vessels, the use of DES was cost-effective.

FUNDAMENTO: Na literatura nacional há escassez de análises de custo-efetividade, comparando stents farmacológicos (SF) versus não farmacológicos (SNF), no seguimento tardio. OBJETIVO: Estimar a Razão de Custo-Efetividade Incremental (RCEI) entre SF e SNF na coronariopatia uniarterial. MÉTODOS: 217 pacientes (130 SF e 87 SNF), com 48 meses de seguimento (média=26). Desfecho primário: custo por re-estenose evitada, sendo efetividade definida como redução de eventos maiores. O modelo analítico de decisão foi baseado no estudo de Polanczyk et al. Os custos diretos foram aqueles utilizados diretamente nas intervenções. RESULTADOS: A amostra foi homogênea para idade e sexo. O SF foi mais utilizado em diabéticos: 59 (45,4%) vs 16 (18,4%)(p

There is a scarcity of cost-effectiveness analyses in the national literature comparing drug-eluting stents (DES) with bare-metal stents (BMS), at late follow-up.To estimate the Incremental Cost-Effectiveness Ratio (ICER) between DES and BMS in uniarterial coronariopathy.217 patients (130 DES and 87 BMS), with 48 months of follow-up (mean = 26 months) were assessed.cost per prevented restenosis, with effectiveness being defined as the decrease in major events. The analytical model of decision was based on the study by Polanczyk et al. The direct costs were those used directly in the interventions.The sample was homogenous for age and sex. The DES was more used in diabetic patients: 59 (45.4%) vs 16 (18.4%)(p0.0001) and with a history of coronary artery disease (CAD): 53 (40.7%) vs 13 (14.9%)(p0.0001). The BMS was more used in simple lesions, but with worse ventricular function. The DES were implanted preferentially in proximal lesions: (p=0.0428) and the BMS in the mid-third (p=0.0001). Event-free survival: DES = 118 (90.8%) vs BMS=74 (85.0%) (p=0.19); Angina: DES=9 (6.9%) vs BMS=9 (10.3%) (NS): Clinical restenosis: DES=3 (2.3%) vs BMS=10 (10.3%) (p=0.0253). Cardiac deaths: 2 (1.5%) in DES and 3 (3.5%) in BMS (NS).the tree of decision was modeled based on restenosis. The net benefit for the DES needed an increment of R$7,238.16. The ICER was R$131,647.84 per prevented restenosis (above the WHO threshold).The DES was used in more complex lesions. The clinical results were similar. The restenosis rate was higher in the BMS group. The DES was a non-cost-effective strategy.

OBJETIVO: Avaliar retrospectivamente, implante de stent (IS) em paciente com doença arterial coronária (DAC), realizado em 7 hospitais do Rio de Janeiro. MÉTODOS: De junho/94 a dezembro/96, foram realizados 2.220 procedimentos, e desses, analisados 783 IS em 660 (29,7%) pacientes, através da coronariografia sem subtração digital. Os diversos tipos de stent, mais freqüentemente, usados foram: Palmaz-Schatz (40,9%), Gianturco-Roubin (29,1%) e NIR (22,0%). As indicações para o IS foram: lesão de novo, 67,9%; lesão reestenótica, 16,0%; lesão com resultado subótimo da angioplastia transluminal coronária (ATC), 8,2%; oclusão aguda ou provável pós-ATC, 4,9%; oclusão crônica, 3,0%. Todos os stents foram implantados com alta pressão, sem controle pelo ultra-som intracoronário. A prevenção da trombose subaguda, na maioria dos pacientes (87,8%), foi feita com o uso de ticlopidina e ácido acetil-salicílico. RESULTADOS: Evolução imediata: a) sucesso no IS em 770 lesões: 98,0% em 646 (97,9%) pacientes; b) sucesso clínico em 634 (96,0%) casos; c) complicações maiores: infarto agudo do miocárdio (IAM) - 1,1%; cirurgia de revascularização miocárdica (CRM) - 1,4% e óbito - 0,8%; d) complicações vasculares com correção cirúrgica e/ou sangramento - 3,0%. Evolução tardia: a) dos 399 (60,4%) pacientes acompanhados clinicamente, a coronariografia de 121 (30,3%) mostrou retorno da lesão no IS em 79 (19,8%) casos; b) freqüência de outros eventos: IAM - 1,5%; CRM - 2,3%; óbito -1,0% e outra ATC ou procedimento similar - 12,5%. CONCLUSÃO: O estudo multicêntrico mostrou que o IS na DAC pode ser realizado com segurança, alto índice de sucesso imediato, poucas complicações e baixa taxa de eventos cardíacos na evolução tardia. PURPOSE: To evaluate retrospectively stent implantation (SI) in patients with coronary artery disease (CAD) performed in 7 hospitals in Rio de Janeiro. METHODS: From June/94 to December/96 2,220 procedures were performed among which we analyzed 783 SI in 660 (29.7%) patients using coronary angiography without digital subtraction. Several types of stents were used: Palmaz-Schatz (40.9%), Gianturco-Roubin (29.1%) e NIR (22.0%). Indications for SI: 1- de novo lesion (67.9%); 2) restenotic lesion (16.0%); 3) sub-optimal results after PTCA (8.2%); 4) abrupt or threatened closure after PTCA (4.9%); 5) chronic occlusion (3.0%). All stents were implanted using high pressure balloon inflation without intracoronary ultrasound guidance. Sub-acute stent thrombosis prevention, in the majority of patients (87.8%) was done with ticlopidine and aspirin. RESULTS: Early outcome: a) the success rate of SI in 770 lesions was 98.0% in 646 (97.9%) patients; b) the clinical success rate in 634 patients was 96.0%; c) the major complications were acute myocardial infarction (1.1%); coronary artery bypass graft (1.4%) and death (0.8%); d) vascular complications with surgical correction and/or bleeding occurred in 3.0%. Late outcome: a) the clinical follow-up of 399 (60.4%) and the coronary angiographies of 121 patients (30.3%) showed in-stent lesion in 79 (19.8%); b) other event rates: myocardial infarction (1.5%); coronary bypass (2.3%); death: 1.0% and other PTCA or similar procedure (12.5%). CONCLUSION: This multicentric study showed that SI for CAD can be performed with safety, high early success rate, few complications and low rate of cardiac events during the late follow-up.