In The News

Vytorin/Zetia/Ezetimibe
The ENHANCE trail, which was recently published evaluated the effects of the new cholesterol lowering drug Zetia on the progression of vascular disease. It was performed in patients with a genetic disorder which leads them to early vascular disease, and measured the thickness of their carotid artery wall before and after treatment. What the trial showed was that the use of Zetia did not slow the thickening of the carotid wall despite lowering the bad cholesterol level.

This trial is not definitive, nor is it applicable to the general population, but it does raise interesting questions about what kind of cholesterol lowering drugs may be most effective. To date, there have been no concerns raised regarding the safety of Zetia. In addition, multiple large scale clinical trials have shown that intensive cholesterol lowering in patients with vascular disease can lead to decreases in heart attack and stroke, and lengthening of life. These trials have almost universally been done with a group of drugs called "statins."

We at ICMG believe that Zetia/Vytorin remains a tool in the physician's armamentarium against vascular disease, when used appropriately. For the most part, this includes using it as a second line agent only in certain patients who cannot achieve enough cholesterol reduction with their primary medications (statins). However, we await further studies which will continue to shed light on this topic.

Update July, 2008. The results of the SEAS study were released. These results did indicate a decrease in risk of vascular disease with the use of Vytorin. While the study was widely panned as being "negative", that is predominantly because it was actually primarily supposed to look at the use of Vytorin in aortic stenosis, an effect which was thought to be minimal at best. Most people take cholesterol lowering drugs to decrease vascular risk, and this aspect of the trial was quite encouraging. Another concern raised by the trial was the increase in cancer in patients taking Vytorin. Analysis of ongoing and already collected data from other trials, as well as the particulars of types and timings of cancers in the SEAS trial, lead most experts to believe that this was a chance occurrence and not a cause and effect scenario. Please do not discontinue any medication before discussing it with your provider.

Drug Eluting Stents
Stents are metal tubes which are permanently implanted to prop open arteries opened with balloon angioplasty. A major downside of stents in the past has been that about 20-30% of the time, the scar tissue that forms on the metal surface can be thick enough to re-block the vessel by itself.

Drug eluting stents, also called "coated stents" or "medicated stents" secrete over time a medication which prevents this scar tissue from forming, nearly eliminating the problem of re-blockage (restenosis). However, this scar tissue can also be protective as it covers the metal stent struts which can provoke blood clots when exposed to blood. Thus, patients with medicated stents need to take long-term blood thinners.
In deciding what type of stents to be used, many different factors need to be considered simultaneously. These include patient preference, technical factors, and ability to take long term blood thinners. Weighing all of these factors can be complex, and we at ICMG believe there is no single right answer for all patients. We believe that ideally, this decision should be made in partnership with our patients prior to stent implantation whenever possible. When in doubt we tend to err on the side of the traditional stents, as these are backed by many more years of data and do not require a patient's commitment to long term blood thinners.

Stents versus Bypass Surgery
This debate has been long running in the cardiology community and promises not to be resolved anytime soon. This is because the technology behind both bypass surgery and stenting is changing very rapidly, and thus comparisons quickly become out of date.
Recent studies have shown that even compared with the newer medicated stents, bypass surgery may hold an advantage in certain patients with blockages in more than one main artery (especially when the left anterior descending or LAD artery is involved).
Once again, at ICMG we believe that this complex decision must weigh many different factors including technical factors and patient preferences. In general, we have always considered bypass surgery as another tool in the quest for cardiac health, and an appropriate option for many patients with multi-vessel disease, even before these studies were published.