A recent article in the financial press (Bloomberg) drew wide attention to inappropriate and excessive use of stents in patients with coronary artery disease (disease in the vessels that supply blood to the heart). Stents are tiny mesh tubes placed in a diseased coronary artery to “prop” it open after a narrowed segment of it has been expanded by a balloon.
Stents Not for Everyone
Blockages in the coronary artery are diagnosed with an angiogram, where contrast dye is injected through a catheter (thin tube) inserted via the groin or the wrist and threaded up to the heart arteries. If a stent is placed, patients are usually maintained on two drugs, which act to interfere with clot formation by platelets. In patients who suffer acute myocardial infarction (“heart attack”), stents are highly effective and lifesaving. In other patients, however, even when there are narrowed arteries seen on the angiogram, stents offer no advantage over treatment with medications (medical therapy.)
When Bypass Surgery Is Better
In circumstances which are now well defined (mostly where the patient has specific anatomic features, reduced heart function or diabetes), coronary bypass surgery (CABG) is clearly better than stents, as measured by patient survival, symptoms and the need for additional invasive procedures.
Unnecessary Stents Cost Billions and Raise Risks
A paper published in the Archives of Internal Medicine last year by Dr. David Brown (formerly Chief of Interventional Cardiology at Beth Israel) analyzed the records of 7,000 patients who had stents placed in eight clinical trials. Such trials recruit patients according to strict selection criteria, yet, by Dr. Brown’s analysis, two out of every three stents placed were actually unnecessary!
Stents are placed in 700,000 patients in the United States every year and represent a significant cost ($110 billion in the last 10 years), and it has been estimated that unnecessary stents cost the health care system in the US $2.4 billion annually! Apart from the initial cost, stent treatment does have risks, both during the procedure and after. A few interventional cardiologists have been prosecuted or disciplined for placing unnecessary stents.
What Is a Patient to Do?
Guidelines published by collaborative groups, such as the American College of Cardiology/American Heart Association and the sister cardiac surgical societies, were created based on the best available scientific evidence. These guidelines set out a plan to treat patients who have specific forms of coronary artery disease. A committee of acknowledged experts sifted and weighted the evidence, and each recommendation is graded for how strong the supporting evidence is.
A ‘Heart Team’ to Protect Patients
Developing guidelines is a difficult process logistically, and new information is published in medical journals almost every week—too fast for the guidelines to incorporate. Crucial protection for a patient comes when you get your healthcare in a system that practices evidence-based medicine, and where non-invasive cardiologists, interventional cardiologists (who place stents) and cardiac surgeons (who do bypass surgery) together discuss relevant studies published in detail in peer-reviewed publications. This “heart team” can then review each patient’s case and—in the light of the guidelines, newer evidence-based practice and the specific circumstances of the patient—arrive at a treatment plan tailored specifically for the individual.
Scientific analysis has shown clear evidence of improved outcomes for patients when their treatment is based on a plan developed by such a team. This is the approach we use at Mount Sinai Beth Israel.
The patient must be an active partner in this decision-making. It is natural to be scared, and to want to avoid invasive surgery, or sometimes to ask for a “quick fix” rather than making a real commitment to being compliant and following recommended diet and exercise plans and taking multiple medications, but the patient should try to follow the carefully considered recommendation of the heart team. There is a lot at stake and much new information to be considered, so ask for a meeting with the heart team and bring a relative or friend to help you make the best choice.
To find an excellent cardiologist who is right for you, please call our Physician Referral Service at 866.804.1007.