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percutaneous coronary intervention

Coronary Stents and Reality; Did Your Cardiologist Come Clean?

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Heart attack risks

Heart stents.  Coronary Stents.  Angioplasty.  Angiogram.  Percutaneous Coronary Intervention (PCI).  Regardless of what you call it, over a half MILLION of them are done per year at a cost of around $18,000 each.

Sounds great.  After all, we’re saving lives with these remarkable procedures that are far, far easier on the patient then cracking open the sternum and replumbing the coronary arteries.

Well yes.  And no.

For emergency procedures, the research is pretty positive.  The sooner you can get this procedure done in the middle of a heart attack, the better the outcomes.  That’s where the clarity ends.  In general, it is pretty well accepted (in the research, but not among cardiologists who do these procedures) that for non-emergency, elective procedures, the data on PCI crashes.  To the tune of about 50% of them being done inappropriately.

These are some serious numbers, serious dollars and serious risks to the patients.  And just in case the patient makes it through the procedure, they have usually earned a year or so on blood thinners.  In coming years, the risk of the stent closing back up again is always brewing in the background.

But all of this is ok, because before you receive ANY medical care, there is something called informed consent.  Under informed consent, it is the obligation of a physician to explain the procedure being done, the risks of the procedure, the risk of NOT getting the procedure and the alternatives.  It would make sense that, as the procedure becomes more invasive, the obligation to fully inform the patient should grow as well.

After all, how can you, as the patient, truly make a decision about a procedure this important (or not) without being fully informed??  You really can not.

Which brings us to this particular study.  In it, researchers reviewed We performed recorded 59 conversations by 23 cardiologists among adults with known or suspected stable coronary disease at outpatient cardiology practices.  These conversations were evaluated for 7 accepted elements of informed constent when it comes to helping the patient make the decision to undergo angiography and possible stenting.  Here’s what they found:

  • A paltry TWO (3%) conversations included all 7 elements of informed decision making.
  • Another eight conversations (14%) met a more limited definition of procedure, alternatives, and risks.

When the cardiologist was more forthcoming and honest about expectations of the procedure, the outcome of the visit was drastically different:

  • If the cardiologist discussed clincially viable alternatives (i.e. medications, lifestyle changes, no treatment–the term for this in informed consent is “uncertainty “), the patient was 20.5 TIMES less likely to choose the procedure.
  • If the cardiologist discussed the patient’s role in deciding about having the procedure done, they were 530% less likely to undergo PCI.
  • If there was an exploration of alternatives the patient was 950% less likely to choose PCI.
  • Neither the presence of chest pain (angina) nor severity of symptoms were associated with choosing angiography and possible PCI.
  •  Overall, better informed patients were 320% less likely to choose angiography and possible PCI.

Granted, this was a small subset of practicing cardiologists and maybe the bulk of cardiology practices do not follow the practices seen in this study.  But, given how rushed many specialist offices tend to be, I’m afraid this is standard.

Overall, though, I think this reflects the disconnect between what patients perceive and what the reality is of the medical procedures that are performed with a high degree of regularity in modern medicine.  The list of procedures and medications that have shown little benefit in the medical research but continue to be used is quite long.

And this is heart disease.  Almost entirely preventable!  For a long time now we’ve known that lifestyle changes produce better outcomes than PCI and yet this procedure is still done on an elective hundreds of thousands of times per year.

So, if YOU had a stent put in, do you feel that your cardiologist fully educated you on the risks, benefits and alternatives?

Angioplasty Sugery and After Stent Restenosis: Not Good News

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Interventional cardiology has made lifestyle changes obsolete. Angioplasty surgery can open clogged vessels and put a stent in. But what about life after stent?

So your cardiologist has told you that you need to have a procedure done. They think the blood vessels going into your heart are blocked, and they want to slice you open near the groin, stick a probe up to your heart and check things out.

If they find a blockage, they’re going to open up the vessel and prop it up with a stent to keep it open.  Here’s where the big decision comes in:  Bare metal stent (BMS) or drug-eluting stent (DES)??

Let’s cover the choices.

Worst scenario that everyone wants to avoid is the full blown, chest cracking coronary artery bypass graft (CABG).  This is the end of the line as far as cardiac procedures (not counting death, which, arguably, is NOT a cardiac procedure….).

When percutaneous procedures began (this is the catheter that is inserted near the groin), they were initially done with just a balloon. The blocked artery was blown up and left alone. The problem was with restenosis, the term describing the re-closure of the artery. This was very common (upwards of 90% of cases) and sometimes let to emergency CABG.

Someone then came up with the idea of propping open the balloon-expanded artery with a piece of bare metal, essentially creating a tunnel. Working better than the balloon alone, but the restenosis rate was still a problem.

THEN, someone thought of coating the stent in an immunosuppresive drug (initially Sirolimus) to kill off the cells trying to grow back into the stent.

At this point, there was much argument about whether the bare metal stents or the drug eluting stents had better outcomes. The research was pointing towards DES being a better long term option. (Research, however, has shown that levels of inflammation are a determining factor here)

So, back to the decision you need to make before your groin region gets sliced and a tube inserted remotely into your vital organ…

Bare metal stent or drug eluting.  What if it REALLY doesn’t matter?

Sure, the short term outcomes seem to favor DES. But who wants to live only another year or two?

This particular study looked at longer, more realistic timeframes.

They also looked at the characteristics of the plaque forming inside of the stent. Lipid containing plaques are more likely to rupture, throwing off a clot and triggering a heart attack.  Not good.

Here’s what they found:

  1. 138 stents were looked at.
  2. In the early phase, under 9 months, the DES had much more fatty plaquing.
  3. In the intermediate phase, between 9 and 48 months the DES still had much fattier plaques.
  4. In the delayed phase, after 48 months the plaquing had evened out, and it was composed of the fattier, more dangerous, material.

So, in the long run, it doesn’t really matter what type of stent you or your cardiologist chooses, after 4 years the news is not good. While this study included a relatively small number of procedures, it seems to fit with what we know about the long term outcomes following this type of procedure. In non-emergent situations, we have known for years that percutaneous coronary intervention does not save lives over conservative care (which means drugs, which is a pretty poor standard to compare PCI to in the first place).

We have spent millions of research dollars to try to find out whether drug eluting or bare metal stents are the best option, and yet neither makes much of a difference in the long run. How much better could that money have been spent on educating the general public about something like refined carbohydrates?

If you happen to be in the population that has had a stent put in, never fear. The fact that this procedure, in someone who was not in the middle of an acute heart attack, has been shown in research studies to be worthless does not mean that there is nothing you can do.

Lifestyle changes will always prevail and have been shown again and again and again to lower the risk of cardiac events and death. Heck–even just adding in dark chocolate can greatly lower your odds of having a second heart attack.

So, if you have suffered a heart attack, what changes have you made to make sure it’s your last?

WAS THAT CARDIAC STENT REALLY NEEDED?

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Had a cardiac stent put in?  Was it really needed?  Basically, it’s a toss up.  50 / 50.

I’ve written before about the reality of this procedure, which has some pretty severe limitations.  Many patients mistakenly believes that percutaneous cardiac intervention (PCI or angioplasty) will prevent them from having a heart attack in the future.  Many doctors do not discourage this opinion, although it is not true in many cases.

About 50% of the time, the only expected outcome of this procedure is angina / chest pain relief.  Sounds good, until you realize that the procedure involves sticking a scope up into your heart itself to take a peek around and has significant risks AND earns you 6 months to a year of Plavix or Coumidin (which carry risks as well..).

Worse, the procedure costs some $50K or more.  Talk about a waste of healthcare dollars!  As a chiropractor constantly dealing with insurance companies wringing our reimbursements down, in recent examples, 50% lower to save money on a fraction of the costs in healthcare, I find it sickening to see this type of abuse that is allowed to occur virtually unchecked. 

This particular editorial laments the waste and abuse in the cardiology realm with this procedure.  Despite strong research suggesting that 50% of the procedures would have been better treated with medications (a topic we obviously won’t get into here…), there has been no behavioral change among most cardiologists.

So, for those of you that think that the typical cardiologist has their nose stuck in medical journals to keep up with the latest research, you might want to rethink that position.  Or worse, they are aware of the research and choose to ignore it for financial gain.  Take your pick.  Either way, it’s not too pretty.

For me, I’d opt for strong lifestyle changes at this point.  Cheaper.  Cuts across much more than just heart disease.  No long term damage (unless you call improved physiology damaging).  And certainly safer.  A no brainer to me.

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