The use of drug-eluting stents necessitates extended treatment with dual antiplatelet therapy (aspirin plus thienopyridine) which may cause bleeding complications and interferes with or even precludes surgery in case this is needed. In addition, from a socioeconomic standpoint, the increased cost associated with drug-eluting stents is a major issue.

Based on these considerations, drug-eluting stents should be avoided

(a) when the expected benefit is low

and

(b) when the risk associated with extended dual antiplatelet therapy is high

After placement of bare metal stents, the risk of restenosis varies considerably based on patient and lesion characteristics. Specifically, patients who do not suffer from diabetes have a substantially lower risk than diabetic patients. Strong lesion-specific predictors of a low risk of restenosis after bare metal stents include short lesion length and large vessel size. Thus, in non-diabetic patients with a short lesion in a large vessel, the risk of restenosis after placement of a bare metal stent is below 10 %. In these subsets, a substantial benefit from drug-eluting stents cannot be expected. These considerations are confirmed by data from randomized studies as well as from registries.

In patients with bleeding disorders, the risk of bleeding complications during dual antiplatelet therapy is particularly high. On the other hand, premature discontinuation of dual antiplatelet therapy for imminent or overt bleeding carries a substantial risk of stent thrombosis with potentially fatal outcome. A particularly difficult patient subset in this respect concerns those in need for anticoagulation, such as patients with atrial fibrillation at high risk for thromboembolic events or patients with prosthetic valve replacement. In these patients, interventional cardiologists are well advised to use a bare metal stent to keep the need for dual antiplatelet therapy as short as possible.

Drug-eluting stents should also be avoided in patients with planned surgical procedure and in those likely to undergo a surgery within the next year.

escardio

Smoking of tobacco was still prevalent in 16.5% of all subjects, even in 30% of men < 50 years of age. 37% and 43% of men and women respectively didn't exercise on a regular basis and didn't intend to do so. Four out of five patients (83.4%) were overweight or obese (Body Mass Index of > = 25 Kg/m2) and most were centrally obese as well.

Blood pressure was not within guideline recommended limits (BP < 140/90 mmHg or < 130/80 mmHg in patients with diabetes), in 71% of volunteers, despite the use of blood pressure lowering drugs by 79% of the subjects.

Among all individuals treated with lipid lowering drugs and/or with a total cholesterol of >= 4.5 mmol/l, only 31% was on target according to the guidelines. Among all subjects treated for type 2 diabetes, fasting glycaemia was < 7 mmol/l in 27% and HbA1c < 6.5% in 53%.

These lifestyle and risk factor results clearly demonstrate a challenging gap between what is recommended in the guidelines based on scientific evidence and what is achieved in daily practice in high risk individuals in primary prevention of CVD. Primary prevention needs a comprehensive, multidisciplinary approach involving the high-risk population, their GP's and other health professionals, a health insurance system dedicated to prevention and all this complemented by a population strategy involving the community at large.

escardio