To Stent or Not to Stent?

To Stent or Not to Stent? That is a question for your Cardiologist.

Dr. Elkin says:

With all the controversy surrounding the treatment of coronary artery disease today, it is no wonder that the public is so confused. Being involved with invasive cardiology and coronary interventions for nearly 25 years, I have seen a number of innovations that have impacted so many lives.

Part of the current controversy surrounds the fact that there are different classifications of patients that receive such interventions. About 80,000 patients receive angioplasty and stents every month, almost a million each year. In the last week of March 2007, a new study found that drug treatment could be just as good at preventing heart attacks as balloon angioplasty and the insertion of stents.

But after reading the media's coverage, one wonders if there is any use for stents at all.

Is this merely an overused, potentially risky and costly procedure that serves as a major source of income to hospitals and cardiologists? Indeed there has been an oversimplification by the media which only serves to confuse the public.

What the study examined was the effect of angioplasty/stents on patients with stable coronary disease. It's not clear how many have stable coronary disease. Some experts estimate that 40% of heart patients have stable coronary disease. Others say that as many as 50% or more fall into that category.

Many patients undergo the procedure to relieve their chest pain. As expected, the new study showed that those given angioplasty/stents did have less chest pain, especially in the first year after the treatment. However, the angioplasty advantage faded over the five years of the study, because drug treatment actually did better in the long term at controlling symptoms.

On one hand the results of the study were surprising that drug treatment fared so well. But on the other hand it supports current thinking about coronary artery disease. We now know that it isn't the mere degree of narrowing of the cholesterol-laden plaque that creates a critical medical problem. The more dangerous blockages in the arteries, commonly referred to as unstable plaques, have nothing to do with their degree of narrowing. They constitute a different structure than stable plaques. Such an alteration in structure and chemical content make these plaques more prone to rupture which makes them so unstable.

But there is a very large population of patients who do benefit from this invasive procedure. Those in the throngs of a heart attack, those with acute coronary syndromes such as pain that occurs at rest, along with those that exhibit acute changes on their electrocardiogram all represent an unstable entity. It is this group that angioplasty/stents actually saves lives. This group usually has have an unstable plaque, which creates a cascade of events possibly culminating in a heart attack.

The facts of this study have been outlined above. But the picture is far from complete. This was not a large study, randomizing only 2,300 patients with stable heart disease to either medical arm or angioplasty arm. There remains a fair amount of discord amongst interventional cardiologists. But it does give us some useful information. There remain many patients with stable coronary disease who will fare well with conservative, medical therapy. Those with acute coronary syndromes, however, will continue to fare better and live longer with the interventional approach.

Dr. Elkin is a board-certified internist, cardiologist and anti-aging medical specialist.

VERY IMPORTANT NOTE / DISCLAIMER: I am offering—always—only general information and my own opinion in these articles. Always contact your physician or a health professional before starting any treatments, exercise programs or using supplements.
©Howard Elkin MD FACC, 2012

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