A recently released study once again shines the spotlight on heart stents, a procedure performed more than 600,000 times per year in the United States.
In effect, the study raises real concerns that stent placement for the treatment of activity-related chest pain (angina) is no better than treatment with medications alone.
Given the relatively high prevalence of heart disease in our society, the general media, including this newspaper, understandably reported on these provocative results. Already we have received a lot of inquiries; patients and their loved ones are concerned and perhaps somewhat confused.
Briefly, a group of respected British cardiologists conducted the study on 200 patients with angina, found to have a severe blockage in one of their coronary arteries.
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All patients were on high-quality medication treatment, then researchers compared stent placement in one half with a simulated sham procedure in the other half of the patients.
After six weeks, there were no significant differences in patient-reported improvement of symptoms or exercise ability in either group.
This study deserves to, and will receive, considerable scrutiny. It was rigorously designed and undertaken with great care. Even so, it has very important limitations.
First, and perhaps most importantly, this study does not pertain to patients who have suffered a heart attack. We know for a fact, based on the findings of numerous studies, that when someone is having or has recently had a heart attack, placing a stent to open up a blocked artery is clearly the treatment of choice.
In these situations, a stent is frequently lifesaving, and may improve longstanding quality of life.
Second, this study was conducted in a small sample of lower-risk patients with good heart function, mild symptoms and blockages in one artery only.
So the results do not necessarily apply to higher-risk individuals with more severe angina, if blockages were found in multiple arteries or if heart function was abnormal to begin with.
In these patients, stenting or even bypass surgery can reduce symptoms considerably, and possibly even protect against future heart attacks or worsening heart failure.
Third, the study followed patients for six weeks. In a larger study published in 2007 on similar patients with activity-related angina who were treated with medications only, most patients did well, but about one third of them eventually required a stenting procedure or surgery when followed for four to five years.
So how should a patient process these results?
If you have already had a stent placed, you should recognize that you are not in any new danger. In fact, current generation stents are remarkably safe and durable. If you or your loved ones happen to suffer a heart attack, you should be aware that in this circumstance, stents are ideal.
If you experience new symptoms of angina, you should consult your primary doctor or a cardiologist. If the symptoms are not severe or very frequent, he or she will likely prescribe a number of medications, possibly order additional testing and then monitor the situation.
Frequently, the medication regimen will reduce or eliminate the angina. If a heart catheterization or stent placement is recommended, it is entirely reasonable to ask careful questions, ensure you are on appropriate medications and get a second opinion.
Finally, it is important to remember that chest pain is a symptom, not a condition.
The underlying disease, coronary atherosclerosis, is best treated with aggressive risk-factor modification, including tobacco cessation, a healthy diet, regular exercise and stress management.
We have known for many years that, in a stable patient, stents do not reduce future risk of heart attacks or death. Rather the emphasis should be medication therapy and, even more importantly, lifestyle measures.
The problem of overuse of stents in stable patients with angina has improved significantly over the last decade, but there is no doubt that there is room for further improvement.
When used appropriately, this procedure has a validated and critical role in the treatment of heart disease. We have placed several thousand stents over our careers, and have seen firsthand the benefits for many of our patients in Kentucky.
So for now, let us not overreact to the results of this small trial, and accidentally throw out the proverbial baby with the bathwater.
Dr. Adrian W. Messerli is director of the Cardiac Cath Lab and Dr. Khaled M. Ziada is the clinical chief of cardiology at the Gill Heat Institute, University of Kentucky HealthCare.
At issue: Star Tribune (Minn.) article, “Heart stents fail to ease nonemergency chest pain, landmark study says”