To Stent or Not to Stent

Blockages in the heart's own blood supply, known as the coronary arteries, are both common and problematic, as they can ultimately cause heart attacks or myocardial infarction, and death.  When someone is experiencing a heart attack due to such a blockage, there's no question that stents, which are minuscule spring-like devices used to open up the occluded artery and keep it open, save lives.  But when someone has so-called 'stable coronary artery disease,' where the blockage has been identified but isn't causing any immediate problems, are they the best choice for treatment when many other studies have shown that use of medicines and lifestyle changes also work?  That's the subject of this week's YouTube and one of the studies we talk about on PodMed, based on a study in the current issue of Archives of Internal Medicine.

The study is a meta-analysis, a type of study Rick and I often opine simply generates more questions that require a different approach to answer.  Yet we are both persuaded by the conclusions of this study, as they are preceded by a host of studies over the last several years all pointing in the same direction.  A total of eight trials enrolling more than 7000 patients were included. Half or more of the patients in each trial had to be treated with a stent. Follow-up had to continue for a minimum of one year.

Outcome data included death from any cause, a nonfatal heart attack , unplanned surgery to restore the blood supply to the heart, or persistent chest pain (angina).  The study concluded that when compared with initial medical therapy alone, the use of a stent did not result in a decrease in death, myocardial infarction, persistent chest pain or angina, or a need to perform surgery.  Aha!  Just as we've suspected for quite some time, so-called "optimal medical therapy" provides good outcomes compared with stents and avoids the risks of both implantation as well as the need for anti-clotting medications after the stent is in place, with their well-known risks.

The authors state that optimal medical therapy has really come of age and now includes statin medications, beta blockers, aspirin and ACE inhibitors.  Most clinicians also recommend the constellation of lifestyle modifications as well, including improving dietary habits, exercising regularly, and smoking cessation if needed.  Rick relates, however, that in his practice he often has patients who decline such a strategy and insist upon immediate intervention in the form of stent placement.  To this I say, then let them doctor-shop.  Not only will medical therapy improve their cardiovascular risk, it will also provide a number of other benefits that are more likely to endure.

Other studies this week include another from Archives on the use of a simple walking test for hospitalized elderly patients to predict who will be able to be discharged to home, and two in Annals of Internal Medicine on rapid flu tests and flu medications, especially timely as CDC data seems to indicate the flu may have finally arrived.  Until next week, y'all live well.

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Julia October 25, 2013 at 6:31 am

Thanks for your blog and practical advice. I always try to keep up on latest innovations regarding cardiology matters. If you are interested, I'd recommend checking this website for latest products (stents etc.): http://www.medicalexpo.com/medical-manufacturer/stent-3677.html

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