Atherosclerotic Vascular Diseases and Failure of Angioplasty - Essay Example

Angioplasty Introduction With the rising burden of atherosclerotic vascular diseases specially cardiovascular diseases worldwide and given the established morbidity and mortality associated with this disease, since its introduction angioplasty did experience an astronomical growth. Throughout the world, angioplasty remains the most frequently performed procedure performed in the hospitals as well as in the discipline of interventional cardiology. This growth had been attributable to better equipment, technological advancement, and better design of the catheters. Better understanding of the procedure has helped this procedure to be acknowledged as safe, and at least in the short term, the success rate of this procedure is high (1999 Heart and Stroke Statistical Update), where successful therapy has been defined as persistence of less than 50% residual stenosis. However, despite the frequency of its usage, research has found that the main limitation of this procedure is restenosis which has been defined as renarrowing of the original arterial lesion at the site of dilatation. Most of the data indicate that around 35% of the patients have restenosis and within six months following the angioplasty procedure (Savage et al., 1998). To improve this statistic and to improve the life-threatening complications following angioplasty or to back up and improve the outcomes of results from balloon angioplasty, the use of stents came into vogue which essentially was balloon angioplasty with introduction of an implant into the arterial area of narrowing that would prevent the renarrowing of the arterial segment (Sculpher et al., 2002). The results of failure of angioplasty are many. The first important ones are unacceptable short and long-term clinical and angiographic outcomes. Next are the high rates of restenosis, high incidence of abrupt closure of the target vessels leading to life-threatening complications, and low incidence of target vessel revascularization, which happened to be the intended objective and indication of angioplasty as a procedure. Although there are numerous studies researching the implications of a failed angioplasty in the clinical scenario, despite having quite a number of studies, investigating the economic issues related to angioplasty as a procedure has been inadequate (Hannan et al., 1997). A second procedure during the same hospital stay, a failed procedure needing another, associated morbidities of a failed procedure all have negative implications for the patient or the providers, although all these scenarios adds to the revenues of the hospital undertaking these. In most of the cases the economic issues related to these fall heavy as a burden to the patient and the nation. As to the argument that economic factors in an offered treatment must be a serious consideration, many studies have spoken in favour of this concept (Asseburg et al., 2007). The need to restrain costs actually affects the decision making in interventional cardiology. There is an increasingly felt need for rigorous assessment of treatment efficiency before offering it. The factors that are currently considered are economic benefits, objective measures of ischemia, and quantitative measures of angina attack rate. While considering the efficacy of a procedure such as angioplasty, there must be serious scrutiny of economic issues and its ability to alleviate symptoms on a time scale (Hannan et al., 1997). These indicated a controversial nature of the findings, although still in hospitals, a primary angioplasty is favoured, since it has been claimed to cause a higher reperfusion rate. Studies report little data regarding cost effectiveness and benefits of the coronary angioplasty, for example PHT has never been compared in terms of cost analysis with primary angioplasty in patients with acute myocardial infarction. Investigation on the economic issues related to angioplasty is difficult because hospital charges frequently fail to reflect the economic costs of angioplasty. The key determinant as described by other studies are hospital time, intensive care unit time, catheterization laboratory time, numbers of balloons, stents, guiding catheters, fluoroscopy time, guidewires, and costs inherent in treatment of other events within at least 6 months following the angioplasty procedure. Along with that in cases of a failed angioplasty or suboptimal clinical outcomes following angioplasty, there must be a cost involved in documentation of restenosis (Cooper et al., 2004). The physician and healthcare professional time and the loss of income in the patients’ hospitalization are added costs which must be weighed against the benefits from angioplasty. Studies have indicated that healthcare resources are limited. Along with the factors indicated above, interventional techniques such as angioplasty should consider both economic issues and clinical factors, which may yield a responsible decision. Other studies demonstrate sophisticated models to assess the economic impacts of angioplasty which considers actual cost and elements that influence costs (Ades et al., 2006). The economic issues are important in the sense that a repeat procedure will always cause burden on the patients, providers, and hospitals. Angioplasty and CABG have little difference in mortality rate and nonfatal myocardial infarction. However, despite the frequency of its usage, search has found that the main limitation of this procedure is restenosis which has been defined as re-narrowing of the original arterial lesion at the site of intervention or dilatation. Most of the date indicate that around 35% of the patients have restenosis and within six months following the angioplasty procedure (Savage, 1998). To improve this statistic and to improve the life-threatening complications following angioplasty or to back up and improve the outcomes of results from balloon angioplasty the use of stents came into vogue which essentially was balloon angioplasty with introduction of an implant into the arterial area of narrowing that would prevent the renarrowing of the arterial segment (Sculphera.2002). From this angle economic assessment of an angioplasty procedure becomes more significant, and consideration to be given the clinical and economic factors while deciding about an angioplasty procedure. Data from different sources indicate the high failure rate of PTCA to the extent of 30 to 40% leading to recurrent angina, myocardial infarction, death, and repeat procedures within 2 years. These occur due to restenosis and have economic implications. The results of failure of angioplasty are many. The first important ones are unacceptable short and long-term clinical and angiographic outcomes. Next are the high rates of restenosis, high incidence of abrupt closure of the target vessels leading to life-threatening complications, and low incidence of target vessel revascularization which happened to be the intended objective and indication of angioplasty as a procedure. Although there are numerous studies researching, Various implications of a failed angioplasty in the clinical scenario there still is need of focused research investigating the economic issues related to angioplasty as a procedure (Hannan et al, 1997). While there are pressing economic issues involved in angioplasty, the priority of health authorities are both effective and cost effective management. There is lack of evidence whether primary angioplasty would be cost effective (Bravo et al., 2006). A second procedure during the same hospital stay, a failed procedure needing another, associated morbidities of a failed proccdure, all have negative implications for the patient or the providers, although all these scenarios add up to the revenues of the hospital undertaking these. Several studies have looked into the economic of angioplasty; however, this must be adjusted and modeled to the geography of the procedure. For such a study, the trial evidence of clinical effects, expression of the clinical outcomes and improvement in quality of life of the patients across clinical areas must be made. However, no existing study on angioplasty incorporates all these economic features (Ades et al., 2006). Therefore, there is limited evidence in favour of angioplasty to be an economically feasible intervention, although some studies done in the UK indicate cost effectiveness despite a time-sensitive limitation (Bravo et al., 2006). Other studies indicate that if there is delay of initiating the procedure angioplasty may be less economical than thrombolysis. This calls for a comprehensive decision making model incorporating the economic factors associated with an angioplasty procedure (Asseburg et al., 2007). This model would ideally incorporate evidence synthesis and a decision analytical model in a single coherent modeling framework that allows all sources of uncertainties propagated and estimates of economic burden incorporated to the indicators for clinical effectiveness (Briggs et al., 1998). Reference List Ades, A., Sculpher, M., Sutton, A., et al., (2006). Bayesian methods for evidence synthesis in cost-effectiveness analysis. Pharmacoeconomics;24:1–19. Asseburg, C., Vergel, YB., Palmer, S., et al. (2007) Assessing the effectiveness of primary angioplasty compared to thrombolysis and its relationship to time delay. a Bayesian evidence synthesis. Heart: Published Online First:3 February 2007. doi: 10, 1136/hrt.2006.093336. Bravo, YV., Palmer, S., Asseburg, C., et al., (2006). The cost-effectiveness of primary angioplasty compared to thrombolytic therapy for acute myocardial infarction in the UK NHS. York: University of York, 2006 Briggs, A. and Sculpher, M., (1998). Introducing Markov models for economic evaluation. Pharmacoeconomics;13:397–409. Cooper, N., Sutton, A., Abrams, K., et al.(2004). Comprehensive decision analytical modeling in economic evaluation: a Bayesian approach. Health Economics;13:203–26. Hannan, EL., Racz, M., Ryan, TJ., et al. (1997). Coronary angioplasty volume–outcome relationships for hospitals and cardiologists. JAMA; 277:892– 8. Savage, MP., Fischman, DL., Rake, R., et al., (1998). Efficacy of coronary stenting versus balloon angioplasty in small coronary arteries. J Am Coll Cardiol;31:307–11. Sculpher, M., Smith, DH., Clayton, T., et al., (2002). Coronary angioplasty versus medical therapy for angina. Health service costs based on the second Randomized Intervention Treatment for Angina (RITA-2) trial. Eur Heart J;23:1291–300. 1999 Heart and Stroke Statistical Update. Dallas: American Heart Association, 1998. Read More