Coronary stents: interventions that come with a cost

~ Carolyn Thomas

by Carolyn Thomas    ♥    @HeartSisters

Remember last month when I covered the topic of “stretch pain” in heart patients who have had a coronary stent implanted?

To recap, temporary post-stent stretch pain in the chest is considered to be due to the dilation (stretching) of an artery while a metal stent is being implanted inside that artery, and it typically occurs in about 40 per cent of stent patients.1   A number of you wrote in with some variation of this question: “Is it still stretch pain if it’s happening months afterwards?”

And now a new study published in the Journal of the American College of Cardiology  suggests that something entirely different might be going on.2         

One of my favourite resources for helping me understand Doctor-Speak in cardiology journals is Dr. John Mandrola, a Kentucky electrophysiologist (a cardiologist who is an expert in heart rhythm issues). In his regular Medscape podcast called ‘This Week In Cardiology’ , he calls this study “a very important and sobering paper.”

(This podcast, by the way, is for healthcare professionals, but Dr. Mandrola’s clear and engaging style makes him a uniquely helpful resource even if, like me, you have never been to med school).

And if you do need any help translating, visit my patient-friendly, jargon-free glossary while you listen to his podcast.

Like all good educators, Dr. Mandrola starts by telling us a story:

“A few years ago, a man from Kentucky had a treadmill stress test, even though he had no cardiac symptoms. But the stress test was positive. A trip to the cath lab showed a significant blockage in a major coronary artery, and he had a stent implanted. Everybody was happy – until three years later when he had to have back surgery. A pre-op stress test showed  everything was clear – thank goodness! But the day after back surgery, he  had acute onset chest pain. Further tests showed a clot at the stent site. He developed what’s called cardiogenic shock. He survived – but just barely.”

When Dr. Mandrola later saw this patient in his clinic, the man asked him:

“Did I need that stent in the first place?”

That’s a very good question for all heart patients to discuss with their cardiologists – preferably before making the “to stent or not to stent” decision.

Here’s why:

Almost all cardiac studies now suggest that invasive cardiac interventions like stents or bypass surgery can and do save lives – but that is apparently true only for those having or at very high risk for having a heart attack, not generally in those with stable angina, or no cardiac symptoms, or who are considered at low risk for a heart attack.3

In the 2019 ISCHEMIA trial, for example, researchers found that stents and bypass surgery are no more effective than lifestyle modifications and cardiac medications in people with moderate-to-severe stable angina – defined as chest pain that comes on with exertion, and goes away with rest. (Although, as I observed at the time, one significant limitation was that, of the 5,000+ participants enrolled in this $100 million study, over 3/4 were men). See also: “ISCHEMIA Study: That Blockage Isn’t a Time Bomb in Your Chest“

Meanwhile, the JACC study looked at 25,000 heart patients over five years; each was living with either a bare metal stent or a drug-eluting stent (DES, a metal stent coated with time-released medicine to help prevent a new clot from forming inside the stent).

Researchers looked at how many of these patients experienced very late Major Adverse Cardiovascular Events long after their stents were placed (MACE =  cardiac death, heart attack or the need to redo the stent).

As Dr. Mandrola explained, in the first year, DES outperformed the bare metal stents. But very late stent-related ischemic events continued to occur, and that rate was rising, increasing at the rate of 2% per year for five years in both DES and bare metal stents, with no signs of a plateau. In fact, the overall MACE rate between 1-5 years was equal to or greater than those within the first year.

Which reminds me of a conversation I had with a cardiologist while I was in the CCU (the intensive care unit for heart patients) after my own 2008 heart attack. I knew nothing about stents at that time, so I asked him, “What’s the difference between this bare metal stent that I have now, and a drug-eluting stent?”  His answer:

“About $2,000.”

But back to our study: the authors, who are interventional cardiologists (the ones who make a living implant stents), concluded this:

“Although DES have markedly improved one-year outcomes, the ongoing risk of very late adverse events from both bare metal and DES is similar.”

In a JACC editorial that accompanied the study’s publication, cardiologists Sabaté and Mack wrote that, if they were to analyze more in depth the type of adverse events, then “only 40% of all adverse events occurring between 1-5 years could be considered stent-related.”

But as Dr. Mandrola wryly observed: “It’s not like nearly half of all late adverse events involving stents is reassuring!”

He admires the study authors, adding that they deserved “kudos for publishing such sobering data.”

Carolyn’s Translation:  The reason that they deserve kudos is that these cardiologists bravely rejected the research practice called “selective outcome reporting” (in which study authors can cherry-pick certain research results by submitting for publication only the positive results that are favourable to the product/drug/procedure being studied and/or the individuals providing/recommending these, while ignoring negative results).

Dr. Mandrola continued:

“This highlights a basic premise in medicine: stuff isn’t free.

“Interventions come with a cost. A stent trades a flow-limiting lesion for a metal cage in the artery—you know, the place where platelets flow by.

“At the stent site, the blood vessel tries to heal – that’s inflammation, and then late focal disease can occur – that we give the funny name neo-atherosclerosis.

“So, when you are having a myocardial infarction (heart attack), stents are great, because you are going to lose heart muscle and maybe die, but …” (like that Kentucky patient Dr. Mandrola mentions) “…when you are stable, every shred of evidence we have shows that stents do NOT reduce hard outcomes compared to lifestyle improvements and cardiac medications.”

Dr. Mandrola concludes his podcast with a wish:

“My hope is that someday, we can find a way to convince society that the clogged pipe frame of treating chronic vascular disease is flawed.”

But that list of adverse events that Dr. Mandrola cites may even go beyond the outcomes investigated in this particular study (namely cardiac death,  heart attack, or redoing the stent).

Cardiologist Dr. Juan-Carlos Kaski is an internationally recognized expert in coronary microvascular disease (MVD, a non-obstructive heart sometimes called “small vessel disease”).  DISCLAIMER: I was also diagnosed with MVD after my 2008 heart attack/bare metal stent. 

Dr. Kaski was a keynote speaker at the 2019 INOCA International “Meeting of the Minds” cardiology conference in London, England, where he told his audience that one in three patients who have a stent successfully implanted can develop MVD as a result of that stent.     NOTE:   you can watch Dr. Kaski’s compelling presentation along with other experts on non-obstructive coronary artery disease here.

He cited, for example, a study published in the European Heart Journal in 2019 that found 20-40 per cent of stented patients develop recurrent or longterm angina after a stent.4

Potential reasons for this post-stent chest pain may include:

  • recurrent ischemic lesion
  • in-stent restenosis (blockage)
  • residual diffuse disease
  • myocardial bridging
  • coronary microvascular dysfunction due to microvascular spasm and impaired microvascular dilation

Dr. Kaski added an important but often under-acknowledged side effect of this reality:

“People coping with chronic angina are more likely to report limited physical function and depression, and are more likely to be re-hospitalized within one year of their heart attack.”

So what can we learn from this “very important and sobering paper”, as described by Dr. John Mandrola?

As he says in his podcast, there are two reminders in these studies to help patients and their physicians who are deciding together whether“to stent or not to stent”: 

  • Atherosclerosis (coronary artery disease) is a systemic, all-over disease, so medical therapy and lifestyle improvements are the right approach.
  • Stents can come with significant downsides – like those late adverse events – and they can help to prop open only one small area of one blocked coronary artery at a time.

♥

  1. Chao-Chien Chang et al. “Chest pain after percutaneous coronary intervention in patients with stable angina”. Clin Interv Aging. 2016; 11: 1123–1128.
  2. Gregg W. Stone et al. “Stent-Related Adverse Events >1 Year After Percutaneous Coronary Intervention”, J Am Coll Cardiol. 2020 Feb, 75 (6) 590-604.
  3. Hannan, E. “Appropriateness of Coronary Revascularization for Patients Without Acute Coronary Syndromes.” Journal of the American College of Cardiology, 2012; 59:1870-1876.
  4. Crea F, Bairey Merz CN, Beltrame JF, et al. “Mechanisms and Diagnostic Evaluation of Persistent or Recurrent Angina Following Percutaneous Coronary Revascularization.” Eur Heart J August 2019; 2455-2462.

♥

Q: Are you surprised to learn that “interventions like stents come with a cost?”

NOTE FROM CAROLYN:  I wrote more about stents and other cardiac interventions in my book  “A Woman’s Guide to Living with Heart Disease“.  You can ask for it at bookstores (please support your local independent bookseller) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

See also:

Did you really need that coronary stent?

Don’t worry your pretty little head over your health care decisions

Dr. John Mandrola’s blog, especially if you live with any type of heart arrhythmia.

You can watch videos of the 2019 INOCA International “Meeting of the Minds” cardiology conference in London, including Dr. Kaski’s presentation on microvascular disease.

Published by Carolyn Thomas

15 thoughts on “Coronary stents: interventions that come with a cost”

    1. Thanks Eva for pointing me to that BBC News Night report. Even more disturbing is this morning’s official statement in response to that report from the European Association of Cardio-thoracic Surgery, which stated:

      “19 February 2020

      “The European Association for Cardiothoracic Surgery (EACTS) has issued a statement following the BBC Newsnight programme (aired on 18 February 2020) saying:

      “The allegations in BBC Newsnight’s investigation are disturbing and underline the need for the recommendations on left main disease in the 2018 Myocardial Revascularization Guidelines to be reviewed urgently by an independent group. In the meantime, we recommend that patients seek the advice of the multidisciplinary heart team at their hospital before deciding which treatment option is most appropriate for them. The latest revelations corroborate the EACTS Council decision of December 2019 to withdraw support from the recommendations on left main disease in the 2018 Myocardial Revascularization Guidelines.”

      So “withdrawing support” from the new treatment guidelines for left main coronary artery blockages seems to essentially confirm some of the allegations in the BBC report.

      Important to keep in mind that the cardiac surgeons were responding to new treatment guidelines that they did not like (surgery has long been considered superior to stents for blockages in the left main coronary artery). I’m waiting for the interventional cardiologists (those who implant stents for a living) to issue their response…

      Stay tuned…

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  2. Hi Carolyn

    This is a very thought provoking topic… I have 4 stents over 10 years and now am getting agina type pains in chest. I developed ventricular fibrillation (VF) after my last one 4 years ago so am very interested in this topic and do not relish any more surgery.

    I have made great changes in my lifestyle as best as I can. I use a Gnt (nitroglycerin) spray as and when needed, and after a chat with my doctor we feel at this time I will keep taking the tablets and exercise and try to eat healthier.

    I live in Ireland, a country famed for its clean food, so hopefully I continue what Dr Dean Ornish and Dr Mandrola suggest.

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  3. Hi Carolyn… Useful info, as usual. I have had four stents. Two of them almost killed me — once I think the cardiologist nicked an artery; I was given so much pain medication that my heart essentially stopped… In the other, the drug-eluting stent may have caused a heart attack…

    Let’s see then — I think two of the stents probably saved my life, and two almost killed me. So I guess it comes out even, just like the research says….

    And I do wish medicine would really, really push life-style changes, thought that might involve working more with psychologists and nutritionists…

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    1. Hi, Dr. Steve – you win some, you lose some, and we’ll call it even! Good grief… Hope that’s not what it’s come to. You are so lucky to be here.

      As Dr. Mandrola said, “A basic premise in medicine: stuff isn’t free.” There’s a cost for everything, as you unfortunately discovered, too. We have to weigh the benefits against potential risks – that is, if we even know the extent of the risks.

      And a stent can affect only one tiny area of the body; it treats symptoms of a disease, but does nothing to address the disease itself. Those lifestyle changes like quitting smoking or regular exercise can benefit every cell of the body!

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  4. When I had my stent placed on June 2 of 2017, I did not realize my life was about to change forever. I dissected in my LAD, my Circumflex artery, and into my aorta. I went into cardiac arrest, had an Impella pump placed and then had a second stent placed end to end bridging the Circumflex artery.

    When the Impella was removed I dissected in my femoral artery. Had to have an emergent cut down to repair that. Six months later had double bypass surgery as I was beginning to reblock with scar tissue. Also developed unstable angina.

    I had always had Premature Ventricular Contractions (PVCs) but began to have paroxysmal issues.

    Now two years post bypass have beginning heart failure with multiple valves leaking and edema in my feet and legs despite treatment with a diuretic. Had genetic testing and discovered I have Classic Ehlers-Danlos Syndrome.

    Stents are definitely not benign in everyone, wish I had known this before I had mine.

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    1. Oh, Michelle…. I’m so sorry that you have gone through all of this. I’ve read that aortic and other arterial dissection is a known complication in EDS, as you have sadly had to learn for yourself. And as you say, you had absolutely no way of knowing how your life would change back in 2017 – how could you?

      You’re likely already aware of EDS resources – like the EDS Society’s virtual support groups – I hope organizations like those can help you feel less alone.

      Best of luck to you… ♥

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  5. I had 2 stents placed end-to-end in my LAD (the widow-maker) 20 months ago. I was 95% blocked and having angina with exertion.

    My cardiologist told me I was already developing collateral arteries to circumvent the near blockage.

    I am now following Dr Dean Ornish’s Plan for reversing heart disease and eating a WFPB (whole food plant based) diet. After reading these studies, I now regret the decision and wished I’d just gone with the life-style changes.

    My question is this: Can stents be removed? Has this been tried? Thanks for all you do to support those of us with CAD.

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    1. Hi Kathi – thanks for sharing that perspective. First, good for you for taking on the Ornish program (just recently beat out the Mediterranean diet as the top heart-healthy diet, did you hear?) You were a prime candidate for the OMT treatment decision (Optimal Medical Therapy = cardiac meds and lifestyle improvements) 20 months ago (you had STABLE angina, collaterals developing, you ticked all the boxes).

      I’m not a physician, but I do think it’s important – once you’ve already undergone a procedure – to try not to focus on the ‘what ifs’. I’m not sure about the risks of removing a stent after 20 months.

      My understanding is that once a stent is implanted in an artery, the cells of the artery wall eventually grow over the stent, meaning that the stent becomes permanently part of the artery wall. Most sources say they can’t be safely removed. I did find an older study in The Annals of Thoracic Surgery about a successful coronary endarterectomy (surgical removal of part of the inner lining of an artery) and stent removal.

      Talk to your cardiologist about this. Good luck to you…

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    1. You’re so right, Pauline – this is not reassuring for those heart patients who already have stents.

      But as I responded to Jill (below) cardiac research has evolved from initially embracing the benefits of stents (e.g. reducing distressing symptoms, etc.) to now discussing the longterm risks. To me, the astonishing part of this particular study described by Dr. Mandrola is that a team of interventional cardiologists (those who implant stents in the cath lab) are actually the authors of this study. That’s almost unheard of. It would be like lawyers agreeing that we should stop consulting lawyers – except in certain very specific urgent conditions.

      I’m not a physician but my understanding is that, for some people (those who cannot tolerate medications, for example, or for people like you who had symptoms of UNstable angina, and certainly those in mid-heart attack) a stent would still be considered appropriate.

      And for heart patients like you, who may have had stents implanted long ago, my suggestion would be “Don’t worry, be happy” – and remember to take all of your cardiac meds as instructed, and to incorporate lifestyle improvements into your day-to-day life.

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  7. I had knowledge of the studies but not all the details. Thanks for the details.

    I found out my Cardiologist is head of a committee within Kaiser Colorado that is looking specifically at Stent vs non-stent decisions being made in his department.

    So I asked him specifically about my stent; “Having read these new studies… Do you still think I needed my stent?” (I was not in the midst of an MI). He said yes, that in my case having CAD, Diabetes, and statin Intolerance I was at too great a risk not to do it.

    I have a question about the “stent related issues”. There is no way to predict the future cardiac issues one would have without the stent…. I would think many people with CAD also have MVD … I guess I value the study but I hope that each decision is carefully based on each patient. Of course, I am 3 years post stent with no issues….So there is that.

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    1. Hello Jill – this is a prickly issue. I’m guessing that very few (if any) physicians in any specialty would admit after the fact that the procedure they’ve performed on a patient was not necessary.

      I agree that each decision should of course be carefully based on each unique patient’s situation. But as I wrote about in this post on the ISCHEMIA study last year: “Some patients may be open to non-invasive options (like lifestyle improvements and medications), but researchers report that heart patients seem to have a distinct preference for invasive procedural interventions (80 per cent) over medications (16 per cent).”

      Plus there’s the intuitive patient preference for doing “something” (stents) rather than “nothing” (taking pills and exercising). If people with the letters M.D. after their names tell us ‘you have a blocked artery’, most of us would reply, “Then you need to get rid of that blockage – NOW!” – no matter what current research is saying.

      The pendulum has now swung both ways, from the early days when the stent was seen as a superior new lifesaving alternative to open heart bypass surgery – and rates of stents exploded (docs called it the “oculostenotic reflex” – you see it, you stent it!) Then more recently, big studies (ORBITA, ISCHEMIA) began sounding warnings about inappropriate use of stents and many interventional cardiologists (like the authors of the JACC study) are being more cautious about the appropriateness of stenting.

      We cannot predict what would happen if we personally didn’t get that stent, but researchers can and do compare longterm outcomes in large groups of patients who either have or have not had stents – which is why we’re hearing so much about this now.

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