ABC | Volume 112, Nº5, May 2019

Original Article Oliveira et al Stents for diabetic patients – VICTIM Register Arq Bras Cardiol. 2019; 112(5):564-570 Table 4 – Percutaneous coronary angioplasty and use of stents in diabetic STEMI patients attended in tertiary Hospitals in the State of Sergipe (SUS x Private network) Coronary angioplasty In diabetic patients SUS (n = 199) Private network (n = 42) p value Primary Angioplasty, n (%) 95 (47.7) 33 (78.6) < 0.001 Type of stent used, n (%) Bare metal 84 (91.3) 3 (9.4) < 0.001 Drug-eluting 8 (8.7) 29 (90.6) Non-Primary Angioplasty, n (%) 63 (31.7) 10 (23.8) 0.314 Type of stent used, n (%) Bare metal 52 (88.1) 0 (0) < 0.001 Drug-eluting 7 (11.9) 10 (100) Although the proportion of patients undergoing PA is higher in the private network (79.7%, p < 0.001), this result may still be suboptimal, since Sergipe is small in size, which should facilitate access to Primary Care. Therefore, there is a need to improve the quality of the service provided, with the training of multiprofessional teams for the rapid and adequate diagnosis of AMI both in the intra- and prehospital settings, so that access to reperfusion therapies for myocardial infarction is optimized. It is also observed that 82.4% of the patients seen at the private network received DES in the PA, while in the public network only 10.5% (p < 0.001) received them. This result in Sergipe at SUS is below the rate of use of DES in the public network throughout Brazil (14%) between the years 2004 and 2005, when these devices were not yet released for use in SUS, according to data of the CENIC Registry. 9 The indication for use of DES follows specific criteria determined by the SBHCI, such as stenosis in the single remaining vessel, intra-stent restenosis, and diabetics with stenosis that can be treated with PA. 3 The wide low use of DES in the public network, however, is justified by possible additional expenses inherent to the procedure. These devices have a much higher cost compared to bare metal ones, and require sustained dual antiplatelet therapy, which further increases their effective cost. 10 On the other hand, the large use of these stents at the private network (in approximately 80% of the total analyzed) may suggest the lack of an adequate protocol of use instructions, extrapolating the classic and evidence-based indications. The high financial cost that this therapy entails is expressive; thus, the cost-effectiveness of DES is potentially questionable in such situations. 11,12 An American study conducted in 2007 by Beohar et al. 12 showed that the use of DES in patients without formal indications that were not tested by clinical trials was related to more severe outcomes when compared to those patients who had a standard indication. Another more recent American study, conducted in 2017, 13 argues that the superiority of DES should not automatically translate into the end of the use of bare metal stents, since the latter still have a potential advantage in specific situations because of the short-term need for antiplatelet aggregation. Patients who will undergo another surgical procedure, either cardiac or not, or those who have high risk of bleeding strongly benefit from the use of metal prostheses. Therefore, DES should not be indiscriminately and randomly used. 13 Regarding the use of DES for diabetic patients, the results also revealed a disparity when the public and private networks were compared. During PA, the DES use rate in diabetics was 8.7% vs. 90.6%, p < 0.001. It is worth mentioning that diabetes mellitus is one of the most common clinical conditions with increasing incidence. They represent a special group of patients facing coronary angioplasty, with large international randomized studies demonstrating high rates of late reintervention and restenosis during the use of conventional prostheses. 14-16 Because in such cases the cost-effectiveness ratio makes the use of the technology economically viable, with less impact on the budget, it is known that DES are allowed for use at SUS in these situations. 9 However, the data found in the present study also reveal a much lower use of this technology in the public service. These findings point to the fact that even after the creation of national legislation, recommendations for drug-eluting stent use have not been followed in Sergipe. In this scenario, diabetics receiving bare metal stents would not have the benefit of reducing morbidity and mortality when compared with the use of DES, as demonstrated in international studies, such as DIABETES, SCORPIUS and ISARDESIRE. 17-19 Thus, failure to follow the current recommendations triggers a warning signal for the need to monitor the adequate implementation of public health policies in Sergipe, as well as recommend the adoption of a system of governance in the use of stents according to criteria adopted by the guidelines in force. The present study has some limitations. First, it is an observational study, in the form of a record. Therefore, there is a possibility that other aspects, other than those found in the analysis, may have influenced the choice of the stent, including logistic phenomena, such as occasional lack of a given material. Secondly, the low level of education, especially in the SUS group, impaired self-information regarding personal medical history, with a tendency to underestimate risk factors and comorbidities. Third, late follow-up of patients was not performed. As a consequence, it was not possible to evaluate whether the disparity in the indication resulted in a significant impact on the restenosis rate. 568