Tuesday, March 27, 2007

Heart stent unnecessary? Maybe

More news coming out of the American College of Cardiology meeting in New Orleans. Too bad Dr. Wes is not there to give us the inside scoop (he he, just kidding).

The theory with heart stents is pretty easy to explain to patients. The paradigm has been that symptoms of angina, or chest pain, are caused by a slight blockage in the tiny heart vessles (see above - image from here). So, why not open the vessel up with a heart stent and relieve the chest pain. Simple, right?

In this Associated Press article, researchers have found that in people with stable angina, medication treatment (meaning pills) is just as good as having an angioplasty procedure and having a heart stent placed.
It involved 2,287 patients throughout the U.S. and Canada who had substantial blockages, typically in two arteries, but were medically stable. They had an average of 10 chest pain episodes a week — moderately severe. About 40 percent had a prior heart attack.

All were treated with medicines that improve chest pain and heart and artery health such as aspirin, cholesterol-lowering statins, nitrates, ACE inhibitors, beta-blockers and calcium channel blockers. All also were counseled on healthy lifestyles — diet, exercise and smoking cessation. Half of the participants also were assigned to get angioplasty.

After an average of 4 1/2 years, the groups had similar rates of death and heart attack: 211 in the angioplasty group and 202 in the medication group — about 19 percent of each.

After five years, 74 percent of the angioplasty group and 72 percent of the medication group were free of chest pain - "no significant difference," [one of the researchers] said.
The results of this study will be published in the New England Journal of Medicine and will send shockwaves through the world of cardiology. This will be a huge paradigm shift in what is the current thinking.

This will set up a philosophical and academic war between the interventional cardiologist (those that make a lot of their living doing angioplasties and stents) and the cardiologist who do few or no angioplasties. It will also be a business war between the drug makers and the stent makers.

It will come down to this question: When a patient has chest pain, what is the better treatment? Drugs AND stent or Drugs WITHOUT stent? We'll have to see how this plays out....

Now, something I am concerned about is what the press report really passed over very quickly. (Surprised that I'm upset at the press again?) What should be emphasized is that this study relates to patients who are medically stable. Medically stable means not actively having a heart attack or actively having worsening chest pain symptoms right in front of you.

I can see a heart attack patient in the ER tomorrow saying, "I just heard this report saying that an angioplasty and stent are not needed. Plus, there have been a lot of bad press lately about stents anyway. I don't want one."

I want to emphazise that in the emergency situation (meaning heart attack and/or worsening chest pain symptoms) -- Angioplasty and stent placement are not only the mainstay of treatment, they have been shown to save lives. So, interpret these study findings how they were presented -- in medically stable patients -- and don't interpret this as a generalization on angioplasty and stents in general.


Donna. W said...

Our doctor asked my husband if he was still taking a certain med given him after heart surgery for arrhythmia; I said, "No, I told the heart doc to take him off that; I read bad things about it on the Internet."

"OHHHHH, the INTERNET," answered Doc D. I think he must hear that more often than he'd like to.

DrWes said...

Never to be at a loss of words... ;)

coaster1robert said...

I have bare metal stent in my left carotid(carotid endarterectomy.),it was surgical place their,everything is holding up,so far.It's my right branch of the carotid,it could not be fix,which caused my stoke. Robert

Dr. Deb said...

Amazing how two little words like "Medically stable" give the report a whole different slant. Media, as you know, is a tricky business.

Chrysalis said...

I'm glad you clarified - not having an active heart attack.

The way the pain of a heart attack was described to me, it was likened to a golf ball sitting on the middle of your chest, and a huge man is standing on top of that golf ball. They said they would have done ANYTHING to stop the pain, stent, cut out their heart, anything...

Ajit said...

A lot has come in the press today.I quote some ....
1]Stents do save lives when implanted DURING OR SHORTLY AFTER a heart attack
2]A majority who receive stents had a relatively stable form of CAD and these were the ones studied recently.In Steven E Nissen's words "It's very intuitive that fixing the narrowing with a stent will yield important long-term benefits,but IT DIDN'T.
3]Stenting is recommended in an attack and those who have no increase in blood flow by drugs or rest.The debate here is not whether to use stents in addition to drugs but whether stents are used in too many seriously ill patients who might live longer with bypass
4] David E Kandzari of Johnson and Johnson..."Modern drugs slowed the progress of CAD but stenting was superior at relieving symptoms so both should be available."
5] Donald S Baim of Boston Scientific..."loss of symptom relief advantage of stents over time was because the trial ended in 2004 when only 3% had recieved drug coated stents.Also one third of the group studied were on drugs treatment ended with recieving stents or a bypass as their symptoms worsened.Most would have been symptom free after 5 years because of stents but still would have been counted in the drug group."
5]Naresh Trehan of the Escort Heart Inst. and Research Centre.India....
"Each form of treatment has its own role.Patients having 40-50 per cent blockages can be successfully managed with medicines.Short localised blocks not at the opening of arteries,a stent would work and multiple blocks with Diabetes then a bypass is required.However there is an overuse of stents worldwide as stent companies have corrupted the system.Many Doctors have misled the patients.Educate the patient and get a second opinion."

Chrysalis said...

Forgive me if I'm about to ask something that you'd rather not answer, but I am curious. What criteria does the patient have to fit into become a candidate for bypass surgery, as opposed to stent placement - to open the blockages found on angioplasty?

Dr. A said...

Of course, I'm no cardiologist but, from what I understand, they look at the percentage of blockage (like 90-100% blockage) and the number of coronary arteries blocked to determine if bypass surgery is indicated. For a stent, it's usually one vessel that doesn't have complete blockage. If I'm wrong on this, I know people will be quick to correct me :)

Chrysalis said...

Thank you for trying to answer that. After I posted it, I was a little nervous someone would say what a moronic question that is.

I am aware of cases where there have been more than 1 stent placed, and the percentage of occlusion was up there, 75-80+, I can't remember the exact numbers now, anyway, I wondered at what point do you opt for bypass surgery over stenting? Thanks again for trying though. I appreciate it.