Stents play a critical role in the lives of those with heart blockages. However, there is an allegation that it is grossly over used in the country. Dr Manoj Kumar, Associate Director & Head – Cardiac Cath Lab, Max Balaji Super Specialty Hospital, Patparganj, New Delhi shares his views on this issue and throws more light on it, with Raelene Kambli
Excerpts
How did the widespread use of stents grow in India?
In the last three decades, there has been a revolutionary change in the treatment of coronary artery disease. Through advances in equipment and technical skills, percutaneous coronary intervention (PCI) is being applied to increasingly more complex patients and lesions. In particular, coronary stenting has emerged as an effective strategy to prevent recurrence after PCI. The recent introduction of drug-eluting stents (DES) has dramatically reduced restenosis rates compared with bare metal stent (BMS) use. Large randomised clinical trials have confirmed the benefits of DES over BMS in terms of decreasing the incidence of in-stent restenosis and the need for repeat revascularisation. As a result, there has been a very rapid worldwide shift in the treatment of coronary stenosis from BMS to DES, including in most Asian countries. Accordingly, PCI with stents is a common procedure in Asia, with >300 000 cases performed each year. In India, as compared to 2005 where DES constituted 55.13 per cent of total stent usage, the numbers in 2006 stand at 72.11 per cent.
Can you share some data that shows the number of the cardiac stenting procedure happening in India?
The data on coronary interventions in India is largely available through two sources – The National Intervention Council (NIC) and the industry. The NIC has developed a web-based system which helps individual operators and institutions to upload their data from time to time. There has been a steady annual rise to the tune of 25-30 per cent in the number of interventions over the past several years.
Can you throw some light on the problem of rising misuse of stents in India? How many stenting procedures are required and how many are done for minting money?
I do not agree with the statement that stenting is done for minting money. Obviously there are always some black sheep in every profession. But that does not mean everyone in the medical fraternity should be painted in the same colour. In my personal practice, stenting is done in 98 per cent of the patients who have over 70 per cent blockage and we have seen a high success rate. In other cases, lifestyle changes are advised which often help solve the problem without surgical intervention. The primary aim is always to treat the disease through prevention and management advice. In cases where stenting is needed, patients and their families are given a free choice between the various types of stents available in the market. They are given the pros and cons of all available options and the associated costs to help them make an informed decision.
The situation of doubt in the minds of the patients arises in emergency cases where time is of crucial importance. Often patients do not realise that in the mind of the treating doctor, the one and only aim is to save successfully the life of the patient. If treatment is not provided within the golden hour, the chances of survival or complete recovery decline drastically and thus he must act immediately. In such cases, the doctors do not get the time to explain to the patients the pros and cons of the different available stents in the market in great detail. They must take a decision based on their experience and the best interest of the patient.
The need of the hour is to raise awareness amongst the public about the various kinds of stents available in the market in different price brackets and the advantages and risks associated with it. This will help clear accusations against doctors who are only trying their best to save the life of the patient to the best of their capability. People need to be made aware about facts such as:
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Reoccurrence of blockages in patients who undergo stenting using bare metal stents (BMS) is 50 per cent whereas in those where drug eluting stents (DES) are used it is only two to three per cent
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In the case of indigenous stents, the cost varies from Rs 20,000 to Rs1,60,000, depending on the different specifics of the stent. Different companies have different prices.
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Both internationally made and indigenous stents, which have a large backing of scientific trials, and long-term successful follow-up data often cost more. The reason for this is that clinical trials are extremely expensive to conduct and the company has managed to prove the efficacy of their product
Tell us about the pricing issue on stenting in India? How has the affordability problem been tackled?
One needs to understand that the difference in price between stents of different companies is because of the difference in the quality of the stents. Depending on the quality, the price varies from Rs 10, 000 to Rs 1,60,000. The stents produced by the foreign companies are priced more as compared to the Indian stents because they have larger evidence in medical literature, long-term follow-up data and good results in clinical trials. However, most of the stents by Indian companies do not have long-term data available. In addition to this, it is not that all Indian made stents are in the low-cost bracket. Some Indian-made stents are priced at par with stents imported into the country from abroad. While the efficacy of indigenous stents has been established over the years, better and more concrete clinical trials are needed.
What are the measures that need to be taken to control stent abuse?
Just like other medical devices, the Government of India can control the prices of the stents, especially in emergency situations where the only aim is to open blockages and restore blood flow. In such cases, the government should provide all hospitals with economical stents that can be suggested as options for patients with financial constraints. This should be made mandatory so that no patient dies because they are unavailable to afford the treatment. In patients who can afford the stents, they should be given the freedom of picking the stent that they feel is most suitable, on the basis of its long-term safety and clinical success data available.
raelene.kambli@expressindia.com