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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?

POOR CIRCULATION IN THE LEGS? AVOID THIS

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Claudication.  It is the medical term for pain in the legs with activity.  It can be neurogenic in nature, meaning that the problem relates to the nerves in the lumbar spine being choked off by arthritis in the spine.  It can also be vascular in nature due to plaquing in the arteries of the common iliac artery that feeds the legs.

Neurogenic claudication can be treated very effective with Flexion Distraction adjusting in a chiropractic office.  Vascular claudication is not so easy to address.  Both conditions are the result of decades of abuse and degeneration–one condition to the spine, one to the cardiovascular system.

Claudication can be debilitating and drastically impact a patient’s quality of life.  Walking time can be reduced to minutes.  Certainly one of the absolute best approaches is to change the lifestyle that put the problem there in the first place.  While this approach encompasses all aspects of lifestyle, exercise is certainly a component.  Although exercise can be painful, exercising within a patient’s abilities can help to improve walking distance.  While this study reports a measly improvement of 78 steps, but it is still an improvement.  Keep in mind, however, that this study used only exercise and did not include a comprehensive overall of the lifestyle, which likely would’ve produced much better results.

But, for those of you who think lifestyle changes are just WAY too hard and want the easy way out, you’re in luck!!  You can have a stent placed in the common iliac artery to improve blood flow.  And since this procedure has been done since the late 1980’s you can assume it’s been well studied and is very effective and damn the cost!

Wellllll….maybe not really all that effective.

This particular study compared exercise therapy to stent placement.  The result for this approximately $10,000 surgery?  A whopping 42 more steps.  Yup.  42 more steps.  What’s that?  Like less then the difference one way to the mailbox?

So what is the bottom line?  Surgery for this condition is not going to get you as far as you might think, but lifestyle changes will take you to a new life.

GETTING A CARDIAC STENT? CHECK THIS FIRST…

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Regardless of whether you’re on the cath table just starting to fade away from the anesthesia or are reading this from home, inflammation is a major, massive player in heart disease.  We’ve spent so much time focusing on cholesterol levels, mainly because we had a drug that could lower this value so we fit the disease risk factors to the drug that could control that risk factor.  Only recently has inflammation (usually as measured with hsCRP) been looked at as a risk factor.

Percutaneous coronary intervention (PCI) is the procedure in which a cardiologist pokes a camera into your coronary arteries to look at how healthy they appear.  If there is a problem, the common answer is to place a stent in a blocked artery to make sure that blood continues to flow through this artery to feed the heart.  The big problem with this procedure is that these stents have a tendency to plug back up again (restenosis).  Two schools of thought exist– the use of bare metal stents or the use of drug eluting stents to lower the risk of restenosis.  In this particular study, researchers determined that the inflammation levels were a major determinant in which a bare metal stent or a drug eluting one should be used.

Less simplify this.  Manage your inflammation long before you need a stent and the decision won’t be there to make.  Exercise, live an anti-diabetic lifestyle, stress less, add a multivitamin, D and mixed tocopherols (Vit E) as well as fix any silent sources of inflammation like poor oral health, poor gut health or food allergies.

http://www.sciencedirect.com/science/article/pii/S0002914911003869