by Carolyn Thomas ♥ @HeartSisters
A clinical review paper published in the European Heart Journal, under the intriguing section called “Controversies in Cardiovascular Medicine”, revealed a controversy that I’ve written about (and experienced in real life): post-stent chest pain.1
This clinical review started with a polite acknowledgement that “procedural success is routinely achieved” in heart patients when blocked coronary arteries are treated with an implanted stent. But immediately following the niceties about the success of the procedure, review authors threw in this zinger:
“Persistence or recurrence of angina after a stent is well-recognized and may affect 20–40 per cent of patients during short to medium-term follow-up.”
Whaaaaat?! That’s like the old hospital joke: “The operation was successful – but the patient died!” And how can a stent procedure be dubbed a success if up to 40 per cent of patients suffer persistent or recurring chest pain afterwards?
The lead clinical review author Dr. Filippo Crea’s stellar team of international colleagues (from Italy, Germany, Scotland, England, the United States, Australia and Japan) then added:
“Despite procedural success implanting the stent, angina may persist or recur in a large proportion of patients, which is frustrating for patients and clinicians.”
“Frustrating”? Now there’s an under-statement.
In my experience, I can tell you that few symptoms are as terrifying as chest pain. We feel relieved when we’re able to get medical help before it’s too late, and further relieved when we’re told that a coronary stent is a treatment option to help restore blood flow to struggling heart muscle.
We’re assured, or we hope, or we just assume that this new stent will help to keep a blocked coronary artery unblocked – so that our chest pain goes away, and reduced blood flow to the heart muscle will be forever restored. But although our skilled doctors can stent us, and bypass us, and swap out weak heart valves for good ones, and zap our hearts’ wonky electrical bits, what they cannot do is change what happened – likely decades ago – that caused the heart damage in the first place.
In my own case, alarming new chest pain symptoms returned in the weeks following the implanted stent that had interrupted my “widow-maker” heart attack. My cardiologist suspected what doctors bluntly call “stent failure”, and booked my immediate return to the cath lab to check if the coronary stent itself had become blocked. The interventional cardiologist who did this second procedure that day told me afterwards, however, that the new stent in my formerly-blocked left anterior descending coronary artery looked “pristine” on the angiogram screen. No new blockage. No stent failure.
He then showed me my chart, on which he had written “NOT CARDIAC!” Yes, with an exclamation mark! He wrote that because he could not see a blockage on that screen.
But those two words “NOT CARDIAC” are an example of what Dr. Crea and his colleagues call “detection bias”.
Historically, they explained, cardiac clinicians have tended to focus on identifying a blockage in an artery that’s threatening normal blood flow to the heart muscle cells – the cause of most heart attacks.
And patients also believe that what’s blocked needs to be unblocked.
We believe this about a blocked coronary artery in precisely the same way we believe it about a blocked kitchen sink drain. Dr. James Hansen of The American College of Cardiology recently observed that, for interventional cardiologists (i.e. the ones who make a living implanting stents), “the urge to fix things is understood and expected.” Detection bias is also called “the oculo-stenotic reflex” – roughly translated as “See it – Stent it!”
But we now know about non-obstructive heart disease from published cardiac research over the past 75 years, a history outlined in the cardiology journal Circulation. And we know that this diagnosis is most frequently seen in women. In these cases, there are usually no detectable blockages – even with severe cardiac symptoms like mine. Dr. Crea’s previous research had reported that post-stent angina may be caused by the impaired ability of the small microvascular blood vessels to dilate, resulting in a reduction of blood flow to that heart muscle, similar in severity to the pain caused by an actual blockage or spasm.2
After my heart attack, my secondary diagnosis was coronary microvascular dysfunction. Lots of chest pain, but this time “pristine” blockage-free coronary arteries.
Previous researchers have called this post-stent angina “stretch pain“. Most stretch pain symptoms appear to be temporary, likely due to dilation and stretching of a coronary artery that’s caused when the artery is treated with an implanted stent. 3
The 2020 article I wrote here called Post-Stent Chest Pain has become one of my most widely-read Heart Sisters articles, attracting hundreds of concerned reader comments so far – most of which come from scared patients who had never heard of stent-related stretch pain. So no wonder they’re scared when unexpected new cardiac symptoms start up again.4
I now suspect that my Post-Stent Chest Pain article’s popularity is largely due to two main factors:
1. Many heart patients with a stent implanted are not warned by doctors or nurses about this common post-stent chest pain before hospital discharge.
2. Many heart patients who do experience post-stent chest pain have doctors who don’t believe that post-stent chest pain actually exists (or even that coronary microvascular dysfuntion exists).
But as Dr. Crea and his research team explain even further:
“Importantly, persistent or recurrent angina post-stent is associated with a significant economic burden. Healthcare costs may be almost two times higher among patients with persistent or recurrent angina, post-stent, vs. those who become symptom-free.
“However, practice guideline recommendations regarding the management of patients with angina post-stent are unclear. And few studies have systematically addressed the mechanisms responsible for this recurrent angina.”
Dr. Crea also wrote that current European Society of Cardiology guidelines on stable coronary artery disease now acknowledge the link between coronary microvascular dysfunction and post-stent chest pain. Prior research suggested this pain might be similar to that experienced with an actual blockage or microvascular spasms of the artery.”
Dr. Crea and his research colleagues are correct when they remind us that coronary stents are indeed life-saving for patients in mid-heart attack, but many patients living with stable angina (meaning chest pain that typically increases with exertion and eases up with rest) believe that their stent will end their angina symptoms – which may not be the case at all, as their study adds:
“Patients with persistent or recurrent angina post-stent present an unmet
clinical need. Recent studies suggest that stents may not be relied
upon to improve angina symptoms.“
“In clinical practice, stents for stable angina patients are currently a
‘one-size-fits-all’ approach, potentially useful for symptom relief in
some symptomatic patients found to have obstructive
coronary artery disease. In other patients with
more extensive vascular dysfunction, stents alone may be ineffective.“
“More research is warranted into the prevalence and clinical significance of coronary vascular dysfunction in patients undergoing stent placement.”
Despite my blocked kitchen sink drain example, not all blocked arteries require a stent to help unblock them. Here’s how Harvard cardiologist Dr. Dara Lewis, for example, explained the surprising results of the 2019 ISCHEMIA research trial: 5
“Most cardiologists would have predicted that more invasive options like coronary stents would be superior to non-invasive options like medications and lifestyle improvements. But in the large $100 million ISCHEMIA study, there was no significant difference between the two groups in terms of rates of heart attack, death or hospitalization for worsening chest pain.
Speaking of medications, a number of heart meds seem promising in treating non-obstructive heart disease (e.g. nitrates – including nitroglycerin – plus statins, calcium channel blockers, ACE inhibitors or beta-blockers). It’s apparently a trial-and-error exercise, however, between the prescriber and the prescribee. As a heart patient living with refractory angina for over 16 years, I would never leave home, for example, without my trusty nitro spray.
MY USUAL REMINDER: I’m not a physician and cannot advise you on what to do. Please ASK YOUR PHYSICIAN for expert medical advice on your unique issues.
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1. Crea, Filippo et al. “Mechanisms and diagnostic evaluation of persistent or recurrent angina following percutaneous coronary revascularization”. Clinical Review, “Controversies in Cardiovascular Medicine”. European Heart Journal (2019), 1–10.
2. Jeremias, A. et al. “Non-ischemic Chest Pain Induced by Coronary Interventions: A Prospective Study Comparing Coronary Angioplasty and Stent Implantation”. Circulation. December 1998: 2656–265.
3. Chao-Chien Chang et al. “Chest pain after percutaneous coronary intervention in patients with stable angina”. Clin Interv Aging. 2016; 11: 1123–1128.
4. Ong P et al. “Coronary vasomotor abnormalities in patients with stable angina after successful stent implantation but without in-stent restenosis.” Clin Res Cardiol 2014;103: 11–19.
5. Lewis, Dara. “Medications as effective as stents for most with coronary artery disease”. Harvard Health. 2019.
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NOTE FROM CAROLYN: I wrote more about cardiac symptoms in my book A Woman’s Guide to Living With Heart Disease (Johns Hopkins University Press). 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).
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Heart Sisters 
Hi Carolyn,
I have ischemic cardiomyopathy, spasmatic artery disease, and suffered an AMI/ STEMI widowmaker. I have a microvascular disorder as well as a number of other cardiac issues.
My cardiologist worked on me from 7:30ish am until after 4pm trying not to place a stent and my artery kept collapsing. I clinically died three times until he was forced to stent me. My stent is in my LAD right outside of my aorta.
I suffer with coronary artery disease involving native coronary artery of native heart without angina pectoris. I am a heart patient that doesn’t have chest pains. I went to the ER for what I thought was an uncontrollable bronchial asthma attack. I had three arteries along the right atrial that were spastic but that are too small to stent.
A cardiac cath a month ago found the arteries have calcified and are permanently open at 50%. I’ve never been to the ER for chest pains and EKGs are the reason I ended up in the cath lab. The last one stating that I had possibly had a few new heart attacks.
Having 7 major cardiac conditions, they place me under cardiac observation when I show up with anything that is off because I’ve never presented with cardiac symptoms.
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Hello Robin,
You are indeed a rare example of the utter mysteries of how the human body can function! Serious heart conditions with no chest pains are unusual – but clearly, based on your own results, can still occur with non-chest symptoms – like your symptoms of “uncontrollable bronchial asthma attack” that brought you to the Emergency Department for help. I’ve met women whose only heart attack symptoms were “lips turning numb” or “persistent cough” – yet like you, NO chest pain.
The real silver lining with your circumstance is that your medical team knows by now to place you under cardiac observation no matter what your symptoms are.
Good luck to you! ❤️
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Just one more experience I had that might be relevant. . . In 2020, I had a post-ER follow-up visit with a new cardiologist. My visit to the ER was for unexplained episodes of chest pain. I brought the cardiologist a chart of my chest pain episodes with dates, times, intensity and duration and activity at the time of occurrence.
Most of my chest pain does not occur with activity. The MD said this pattern of chest pain did not require a cardiac cath. And since I Was interested in research, he told me to go look at the ISCHEMIA study. I did.
The conclusion when comparing stents to medical intervention and life style changes was as you quoted “there was no significant difference between the two groups in terms of rates of heart attack, death or hospitalization for worsening chest pain.”
However, in the study,(if I remember correctly) as they coincidentally found that stenting did relieve chest pain symptoms significantly and they alluded to a possible placebo effect!!!
I felt like my doctor was saying to me: you don’t need your chest pain investigated because it won’t make any difference. Just go change your life style, you’ll get the same benefits as having a stent.
But quality of life is what’s really important to me versus when dying sooner or later and if a stent would help my chest pain I want one – but I’ll never find that out because my ongoing sporadic chest pain doesn’t fit the criteria for a cardiac cath.
Sorry for the long windedness today. . . and actually this week has been relatively chest pain free 🙂
Blessings!
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Hi again Jill – like you, most of my refractory angina symptoms do NOT occur during exertion (unlike blocked-artery symptoms). You are so right – quality of life is what’s important.
The studies looking at stents to reduce chest symptoms are in fact mixed. And as Dr. Crea and his cardiologist colleagues have reported, up to 40% of stent patients may indeed experience “persistent or recurring” chest pain FOLLOWING the procedure – which can feel shockingly unexpected for those patients who were anticipating feeling better, not worse.
By the way, a series of videos filmed at a meeting of experts on coronary microvascular disease at the 2019 INOCA International “Meeting of the Minds” cardiology conference in London, England,
is a goldmine of info for patients living with this condition – If you haven’t seen these yet, I think you’d enjoy watching. . . ❤️
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My case is somewhat similar to this (without the stents).
You don’t even need to respond to this, Carolyn, it’s more of a “thinking out loud” exercise on my part.
I experienced chest pain for the first time after the aneurysm in my ascending aorta was repaired with a Dacron graft. It continued intermittently afterwards, but wasn’t too bad.
I then developed atrial fibrillation and have had 2 ablations with a cardioversion in between them. The most recent ablation seems to have “fixed” the a-fib, but chest pain has increased in frequency.
Could it be that many more women have microvascular dysfunction than is currently believed? And if that’s the case, perhaps any kind of intervention increases the risk of post-operative chest pain/angina in women?
In the meantime, I carry my nitro and hope I never have to use it.
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Hi again Deborah – always a pleasure to respond to any of your ‘thinking out loud’ comments!
So basically, your body has so far endured an aortic aneurysm, atrial fibrillation (and at least three associated treatments) – and now increased chest pain.
As you know, I’m not a physician – just a lowly heart patient – but your observation: “Perhaps any kind of intervention increases the risk of post-operative chest pain/angina in women?” sounds completely sound – and deserves to be the focus of future cardiac research!!!
I suspect clinicians would take women’s unexplained non-obstructive chest pain more seriously if they read about it in future journal articles. . . .
Take care! Stay cool. . . ❤️
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After reading these posts about post procedural chest pain I was reminded of my double whammy December 2017.
In November of 2017 I started having rapid heart rates (SVT) with pre-syncope. As I think back, I was also having pain in my back, between my shoulder blades but it took a back seat to my almost passing out.
So around the middle of December 2017 I had an ablation procedure which cured my SVT.
Then the pain between my shoulder blades became more noticeable and was occurring whenever I took a brisk walk. Two weeks after my ablation I was off to the Cath lab for a stent in a 90% blocked circumflex artery.
Which came first the chicken or the egg?? Did one cause the other?
The chest pain I get now is not at all like the back pain that sent me to the Cath lab, so I guess the stent helped that. And then there is the chest painzz so I get just from having Hypertrophic Cardiomyopathy! LOL
When will they invent that Star Trek Scanner that can diagnoses EVERYTHING! I’m going to go watch the videos on microvascular disease you suggested.
Enjoy your Sunday!
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You know, Jill, I think you’re on to something when you write about how certain symptoms (feeling like you’re going to pass out) are so unusual or so distressing that they can make unrelated symptoms (even serious symptoms like that pain in your back) far less noticeable.
I had that reaction when my soon-to-be-former family doctor asked, as she always does, how my ongoing heart symptoms were since our last appointment. “HEART!!??” I replied with a wave of dismissal. “That pain is NOTHING compared to this new arthritis pain in my wrists and finger joints, and in my left knee, and now new arthritis pain in three toes on my right foot. . . ”
As they say, there’s pain. And then there’s PAIN! You’ve had every possible type of pain so far, it seems. In this post called “Habituation: Give Me A Pain I’m Used To!“, I wrote about living with pain that would send most people rushing to the E.R. vs. the kind of pain that we can somehow ‘normalize’!
When they invent that Star Trek Diagnosis Scanner – please don’t tell me! I can only handle one dreadful diagnosis at a time, thank you very much! 😉
❤️
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I was stented in 2017 and re-cathed in 2019 for continued sporadic episodes of chest pain and fatigue. The stent was completely patent.
So, even though they didn’t say “non-cardiac” They kind of shrugged their shoulders.
To this day I go through sporadic episodes of “unexplained” chest pain (and it’s not GERD, darn it!)
I’m on Calcium Channel blockers and do not tolerate nitro or beta blockers. So I just live through these episodes without definitive answers.
My theory on post-stent chest pain, sort of like Dr Crea’s, is that: The stent opens up a large pipe through which blood now flows freely. However, the increased blood flow encounters microvascular blockages and causes a new type of ischemic pain.
As you know so well, Microvascular disease is not visible upon routine cardiac caths. But to think our large coronary arteries have disease and our microvasculature doesn’t makes no sense to me.
So by default my cardiologist says “You probably have some degree of microvascular disease.”
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Hi Jill – I’m not a nurse (as you are) but I agree 100% when you say: “To think our large coronary arteries have disease and our microvasculature doesn’t makes no sense!”
EVERYTHING in our bodies is connected with other body parts (that’s a non-nurse’s explanation of basic anatomy!!) 🙂
I remember reading years ago about something known as “crush syndrome”. It’s apparently what can happen to the human body during a crush injury – in a terrible accident, for example – in which two bad things happen: first, the extreme compression of muscle/bone/nerve cells during the crushing incident which can result in direct tissue trauma, and then secondly the re-perfusion injury once those compressive forces are released during medical treatment – the sudden force of which can cause further injury.
I wondered at the time I read about this if having a blocked coronary artery (blocked enough to cause my heart attack, for example) which is then suddenly unblocked via a stent implant or a bypass surgery graft is a similar sudden re-perfusion injury comparable to a kind of crush syndrome?
Another scenario I often wonder about applies to the argument against choosing a stent vs. lifestyle improvements and optimal medications: a stent or bypass graft can only prop open one coronary artery at a time. But moving the body every day, improved heart-healthy food choices, sleep habits, stress management, or prescribed medications each work to benefit every cell in the body – not just that one artery.
Makes intuitive sense to me.
Take care. . . ❤️
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Thanks Carolyn Thomas for this article!
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You’re welcome Nola!
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I also had the widow maker blockage that we found hours before the almost-heart attack. It was decided that I could not be safely stented, so I had emergency triple bypass surgery as my heart was left dominate with either very tiny vessels on my right, or non-existent.
The two extra bypasses added additional support for blood flow. Sadly, one bypass failed in 6 months and the surgeon said in 20/20 hindsight he should not have done that one. It was too tiny and just scarred shut.
Angina issues set it, and being dismissed from the ER for angina became a common occurrence.
Finally with the help of a fabulous female cardiologist, it was decided since I was safely bypassed, they could now stent my left main coronary artery – and what a difference that made.
But I was not out of the woods yet, as I too suffered from microvascular dysfunction undetermined if this was happening before the stent or now after.
A visit to Mayo clinic in Rochester where a cardiologist prescribed an over the counter supplement called L-Arginine which supports nitric oxide production and healthy blood flow. Wow! What a difference. I take it twice a day. But not all supplements are made equal. Choose wisely. The brand I like is “Pure”. Yes I still take long acting nitro, a beta blocker and a ace inhibitor, but what gave me my life back was an over the counter supplement. You can find it on Amazon and most supplement stores.
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Hello Jennifer – what a roller coaster of dramatic decisions that must have been for you! To be told that one of your bypass grafts had failed just six months post-surgery – and then having your angina dismissed by Emergency Department staff – OUCH!
Your experience with taking a supplement sounds like it had good results for you. But I’m always hesitant to recommend any supplement here because – as you say – they’re not all made equal.
For readers who are thinking of trying L-arginine too, please read this Mayo Clinic report first. It lists a number of concerning side effects to address before deciding, and also includes a list of which patients should NOT take this supplement at all.
For example, Mayo Clinic importantly warns that L-arginine is “not recommended for people who have had a recent heart attack due to concerns that the supplement might increase the risk of death.”
As in all things, tell a doctor before choosing any supplement.
Take care. . .❤️
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About Supplements:
Yes, beware even when it’s a doctor that recommends it. My PCP recommended I take Alpha Lipoic Acid for my peripheral neuropathy . I took it for years.
During a work up for a sudden decrease in kidney function including a kidney biopsy, My nephrologist ran across a very small research study where people with the kidney pathology I had developed were also on Alpha Lipoic Acid. When the supplement was stopped, their kidney function returned to normal.
Thank heaven he saw that study!! I stopped the supplement and my kidney function improved almost immediately.
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YOIKS! Jill, imagine what could have happened had your nephrologist NOT run across that small study!?!??!! I just looked up a number of credible sites for Alpha Lipoic Acid – every one of the 6 or 7 sites suggested that Alpha Lipoic Acid is used to treat peripheral neuropathy. No cautionary warnings for certain kidney patients. Only one site (Mt. Sinai) had this:
“Most studies of oral alpha-lipoic acid have been small and poorly designed. One study did find that taking alpha-lipoic acid for diabetic neuropathy reduced symptoms compared to placebo.”
Not exactly a ringing endorsement of “small and poorly designed” research trials. . .
Arrrrrgh! 😦
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