by Carolyn Thomas ♥ @HeartSisters
Angioplasty poster from the Parsemus Foundation.
Here’s more on the growing controversy surrounding unnecessary coronary stent procedures:
Consider a major cardiac study known as the COURAGE trial*, which signed up over 2,200 volunteers with stable angina, all of whom had at least one coronary artery severely narrowed by cholesterol-filled plaque.
They also had clear evidence of limited blood flow to part of the heart (ischemia), either chest pain or alarming signs on an electrocardiogram or treadmill stress test. Half were randomly assigned to angioplasty plus a stent with state-of-the-art follow-up care. The other half had optimal medical therapy — medications to ease or prevent angina, to protect the heart and blood vessels, and in some cases to boost protective HDL cholesterol. Exercise and healthful eating were also stressed.
NOTE: for a sudden blockage of a coronary artery during heart attack or unstable angina, emergency artery-opening balloon angioplasty followed by the placement of a stent is the life-saving treatment of choice.
After an average follow-up of four and a half years, the two groups were remarkably similar. Getting angioplasty and a stent to hold open a narrowed artery in cases of stable angina did NOT offer any extra protection against a heart attack, stroke, hospitalization for acute coronary syndrome (the umbrella for heart attack and unstable angina), or premature death.
Most patients and doctors overestimate the benefits of angioplasty procedures, suggests a September 2010 survey of patients and their physicians at a Massachusetts hospital. Only 63% of physicians knew that except in emergencies, angioplasties only ease symptoms. And even those who were up-to-date apparently often did not inform their patients: 88% of patients who consented to the procedure mistakenly believed it would reduce their risk of having a heart attack.
In a study of more than 23,000 U.S. Medicare claims, more than half of patients had angioplasty done without first undergoing standard cardiac testing to prove it was necessary. And the rate of those procedures has increased 300% over the last decade.
A Consumer Reports Health article questions this common practice:
“Convenient? Sure. But necessary? Usually not. In non-emergencies, you have time to consult with a heart surgeon and even your primary-care doctor to discuss the options and arrive at the treatment strategy that’s best for you.”
I’ve referred previously here to the groundbreaking cardiac research of Germany’s Dr. Rainer Hambrecht whose 2004 study** was published in the heart journal Circulation. He compared two groups of heart patients with significant coronary artery blockages: one group had stents implanted, the other had no stents but a prescribed program of regular cycling exercise. Here’s what he found:
- Nearly 90% of heart patients who rode bikes regularly were free of heart problems one year after they started their exercise regimen.
- Among patients who had an angioplasty and stents instead, only 70% were problem-free after a year.
In 2009, Dr. Hambrecht and his team presented five-year follow-up findings to the European Congress of Cardiology meetings in Barcelona, confirming earlier study results that regular exercise training is superior to angioplasty at preventing subsequent cardiovascular events. Dr. Hambrecht said at the time:
“It’s difficult to convince people to exercise instead of having an angioplasty, but it works.”
In an interview with Heartwire, Dr. Hambrecht acknowledged that there are multiple forces working against a scenario in which regular exercise is prescribed instead of stenting.
“For one, patients are not motivated to take responsibility for improving their own cardiovascular health – even if it means better event-free survival.
“For another, encouraging exercising is financially less appealing for hospitals. That was my feeling – that hospitals were reluctant to participate in our study, because they derive revenue from revascularization procedures in their cath labs.”
Dr. Hambrecht also believes his research supports the call for cardiologists to take time between the diagnostic angiogram and the revascularization procedure to discuss lifestyle improvement options with the patient, rather than stenting every patient.
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See also:
- Say what? Do Patients Really Hear What Doctors Tell Them?
- Your Health Care Decisions: Don’t Worry Your Pretty Little Head Over Them
- Stent-Happy Docs on Notice in Maryland Health Care Fraud Debate, from my other site, The Ethical Nag: Marketing Ethics for the Easily Swayed
- Cardiologists Accused Of Implanting Cardiac Stents That Weren’t Needed (The Nag)
- “You Can Lead a Cardiologist to Water, But, Apparently, You Cannot Make Him Drink” (The Nag)
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* W.E. Boden. “Optimal Medical Therapy with or without PCI for Stable Coronary Disease”. New England Journal of Medicine, 2007; 356:150316.
** Hambrecht R, Walther C, Möbius-Winkler S, et al. “Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial” – Circulation 2004; 109:1371-1378
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FEBRUARY IS HEART MONTH!
Do at least one thing smart for your heart, every day in February!
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Heart Sisters 
Excellent information! Keep it coming..
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Thanks, Ann!
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Hi Carolyn,
I understand that a patient with a 70-80% blockage may have equal footing with just using medication with stable angina and their outcome being somewhat the same as those having angioplasty and stent. Very good research “IF” you are stable, the operative word being stable. I can see a doctor taking time with a patient in this condition.
In saying that, I know of no medication that works right away. They can give you something to break up a clot, but I know of nothing that can instantly remove plaque or make a collapsed artery open. Nor of a drug that will make it stay that way until the heart heals. I fully understand the need for all of this research but at what cost. Something of this nature doesn’t effect just those with a small amount of blockage but it will effect us all. I truly understand that there is always a margin for error, and that we have doctors that are only in it for the money. Btu it has always been my understanding that ruling on things of this nature hurts the good as well as stops the bad.
I had been suffering an AMI for just about twenty four hours. I fully understood what my cardiologist was saying, the thing that threw me off was my having a HA. I didn’t just have a HA, I died and I am now living with CHF but I am living. I never want a doctor to have to think on if I truly need this form of treatment or if a tiny piece of chicken wire will save my life.
True I didn’t know all about a stent at that point but that was not a time to go into a discussion about the stent. Sometimes we have to trust and I do mean TRUST someone other then ourselves. Heart medicine is not an exact science and no one is perfect. But I want you to look at the stent in terms of science.
Chicken wire/stent both are metals. One is outside in the elements, the other inside a blood vessel. The man who sold you the chicken wire can not tell you that over time that the chicken wire will not deteriorate, there are corrosive elements in our air that will cause it. Common sense should tell you that no one can put a wire in your heart and tell you it will last forever, your blood contains far more corrosive elements than does the air. Your own antibodies are attacking it on a daily bases and each time your heart beats your artery constricts around it. All any of us can do is follow orders for maintaining it as long as possible. I am fully aware that if I live long enough I will have to under go bypass surgery. All any of your doctors are doing is teaching you how to maintain your stent so that it is later and not sooner. Simple high school science.
Robin
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Hi Robin – please read my response to Kaylen for the definition of “stable” vs “unstable” angina. My (limited, patient-only) understanding is that the degree of blockage does not necessarily define stability.
Clot-busting drugs (called thrombolytics) are actually demonstrably effective in dissolving clots in coronary arteries. For example, an analysis of the National Registry of Myocardial Infarction found that women treated with the clot buster tissue plasminogen activator (tPA or Activase) were twice as likely to survive compared with those women studied who had not received clot busting drugs.
You might also be interested in the work of cardiac researcher Dr. Rainer Hambrecht of Germany (mentioned in the article above).
More on this at: “What Prevents Heart Disease Better Than Any Drug?” –
Also, I believe that it’s counterproductive to say things like “I died”. No, you did not die, or you would most certainly not be reading these words right now. You did survive an acute myocardial infarction – congratulations!
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I had an angioplasty last year for unstable angina that was found to be a 99% blockage (LAD), so it wasn’t optional and I did talk to a heart surgeon at the time to see what he recommended – though I was a bit drugged up by that time. When I first met with the cardiologist and learned of my issue, I was in a panic over the procedure and my cardiologist kept insisting there was no reason for me to be upset and angioplasties are very common, they do them all day, low-risk, etc.
I was all alone and crying nonstop for about an hour before they started the procedure and he didn’t think anything of my anxiety, just kept insisting that it was going to be fine and I was over-reacting.
I have a new cardiologist now. But I’m a bit surprised to read of the risks involved, as these were not presented to me when I was being admitted for an angioplasty. They made me feel like it was the same as having a root canal really, but less painful.
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Only a physician who has never actually been in your shoes (or rather in your flimsy hospital gown) while experiencing frightening cardiac symptoms would ever dare to describe your response as “over-reacting”. See more info about this very common problem of doctor-patient miscommunication at: “Do Patients Really Hear What Doctors Are Telling Them?”
You make a good point here, Kaylen, about the difference between “stable” (symptoms come on with exertion, go away with rest) and “unstable” angina (symptoms come on more frequently, more intensely and even when at rest). Current practice guidelines do not recommend angioplasty/stenting for treating stable angina.
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So very sorry to read of yet another woman treated this way. I was at the ER again today due to a change in the chest pressure I’ve been feeling – (still not diagnosed with having had a myocardial infarction) – but I am getting the same treatment. In my case, I asked too many questions – it says that in the notes – so they decided not to pursue cardiac catheterization for me, despite the evidence to do so. And, I’m certainly more in favor of not having one than taking the risks. However, yet again, it’s “all” my fault. You see, if I had “just done what was advised,” and not asked so many questions about the procedure, it would have been done. I can’t use profanity here…
Anyway, the ER physician sent me home with a diagnosis of “angina,” in addition to coronary artery disease. Although I wasn’t given nitroglycerin, so came home with the same discomfort I had when I went there this afternoon. When I asked about taking a nitro – I was told I could take one if I wanted to. As I have yet to take a nitro tablet, if THEY didn’t think I needed to take one…
It’s so very comforting when the ER physician sends a (silent) message that he wouldn’t be managing my care this way. Right. But enough about me… I am sorry.
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