Dear Mehdi, You've made an excellent point here.....the socioeconomic impact in interpreting the data of BMS and DES. It's likely an unmissed but important factor.

Dr. Topol, I enjoyed your blog on DES; however I am concerned with the interpretation that these devices are no longer ‘guilty’. Several independent analyses have confirmed an increased risk for late DES thrombosis which is unquestionably associated with morbidity and mortality to the individual patient. All of the recent registry analyses are prone to bias no matter how much propensity analysis is performed. In the Ontario study for example, the penetration of DES was less than 40% and stable during the period of follow-up. This shows that the operators were restrictive in who received a DES, and it is likely that DES were not implanted in patients who were sub-optimal candidates. At our institution, BMS are more frequently used in patients with limited life-span, medical non-compliance, acute coronary syndrome, extensive co-morbidities, bleeding problems, or upcoming surgical procedures. While these are good devices, we should continue to be more selective, rather than going back to unrestricted use.

Dr. Topol, Thank you for your comments. I certainly agree with you that DES should not have received such sensational headlines. I also did not feel that you were calling for unrestricted DES use. Rather my concern was more that the cardiology community could tend to go back in that direction, especially in light of recent data. Regarding the Stettler analysis; this was a comprehensive network analysis that indirectly derived data from head-to-head trials, in addition to DES versus BMS trials. While this type of analysis is the largest to date, it’s methodology is unprecedented in the cardiology community and potentially could have bias. I do agree with their finding of no excess mortality, as this has been shown in other studies; however the finding of decreased MI from DES will need to be confirmed. In summary, DES are excellent devices in appropriately selected patients. For these individuals we may learn that they can reduce MI through their marked reduction in restenosis, although for less optimal patients they have the potential to magnify harm.

Dear Dr. Topol, I am a pediatric cardiologist at UCSD. I spend most of my time doing research on genetic causes of congenital heart disease. The reason I'm writing is to let you know that our program was just selected as an auxiliary site for the Pediatric Heart Network's/NIH-sponsored prospective trial comparing atenolol to Losartan for patients with Marfan syndrome. As the PI for San Diego, I am trying to recruit as many patients as possible. Participating in the study would in no way take the place of their standard cardiology care that they are already receiving. The upper age limit is 25 years, so I wanted to see if you might be able to identify any potential patients from UCSD that might qualify and be interested in participating. The National Marfan Foundation is also paying travel expenses for any participants that live outside the areas where there are participating centers. So, if any of your patients have any friends or relatives outside of San Diego with Marfan syndrome that are interested, they could participate too. I look forward to hearing from you. Thanks! Sincerely Yours, Paul Grossfeld, M.D.