Why do DES not alter long‐term outcomes? Why would they, after all, it's a chronic disease

Abstract

In this issue of the journal, Garcia-Garcia et al. report on 3-year outcomes in a group of patients undergoing DES stenting for chronic total occlusion compared to a historical BMS control group. As previously reported by this group and others, short-term outcomes seem to be superior with DES stenting, at least out to 1 year. Why the apparent equivalent outcomes at 3 years?Coronary disease is a chronic disease that, given similar patient populations, should progress at similar rates yielding similar long-term outcomes irrespective of the stent type used. There is no doubt, in CTO as well as non-CTO lesions, that stents treat only the relatively small section of the diseased vessel in which they are implanted. BMS impacts restenosis by overwhelming the impact of late loss by maximizing the initial result and eliminating negative remodeling. They have no impact on the chronic disease. Drug eluting stents have the additional impact of truncating the healing process resulting in mitigation of late loss. Drug eluting stents also have no impact on the longterm disease process within the implanted vessel or obviously anywhere else for that matter. Atherosclerosis affects all the coronaries to a variable degree, and it is also a systemic disease as well. A device that is generally less than 1-in. long and elutes a drug for a relatively short period of time could not possibly impact long-term outcome. What does? Without a doubt it is medical therapy of the underlying disease. This is a systemic treatment for a systemic disease.Unfortunately, Garcia-Garcia et al. do not report the medical therapy given to these patients outside of antiplatelet drugs. The evidence base supporting medical therapy of coronary disease is large and convincing. In large part it is very likely to explain the drop in cardiovascular death in the United States over the last several years. To some degree medical therapy is also likely to explain part of the drop in the number of coronary bypass operations performed in this country with a hint of an impact on percutaneous coronary intervention rates, well before the recent controversies and the wide use of DES.It is time to start collecting and reporting the medical therapy of patients undergoing coronary intervention. Otherwise, how will we ever really know what is responsible for long-term outcomes? Is it the stent or the underlying disease and/or its medical management? As we go forward with registries and randomized trials designed to look at the long-term impact of DES, we must know this information. Hear my plea!