What happened to stents not being recommended any more for coronary artery disease?

In My Humble Opinion
1

The question calls for a mix of fact and opinion, so I’m putting it here.

A few years ago–3, 5, not sure–it was reported quite a bit in the media that a study had shown that putting stents in after a cardiac catherization did not improve outcomes, and it was recommended simply to use medication.

My mom, however, has had three catherizations in two months, and two within a couple weeks of each other. The first was done on an emergency basis, the second was a followup, and then, frustratingly, she required yet another. They put in stents each time, and the total now is 6 or 7.

So I guess stents are still being used. Moreover, it seemed to be the automatic choice of the doc.

My questions, therefore:

  1. Did that research end up not “taking,” with stents never being eschewed? Or was there a dip for a bit in use with them coming back thereafter?

  2. This is a matter of opinion, but I’m frustrated with docs. At any given stage in an illness, they talk with complete confidence about what they’re doing, and if that doesn’t work, there seems to be no “debriefing” on why that is the case. This was literally the conversation (as reported by my mother) that she had with the doc when she was on the table:

Mom: We need to stop meeting like this.
Doc: Yeah. What the hell?!

What the hell indeed. Maybe tell us why or why not decisions made thus far were a good idea or not instead of just blowing it all off?

I am not even saying that the doc did anything wrong. It was probably “standard of practice” the whole way. I’m bitching about the way it was or was not talked about. And it’s not just this doc but docs in general who do this.

Thoughts on that?

I could go on and on. My dad died of heart disease in 2001. That’s a vast tale of bullshit and medical failures (and technology quite rapidly shifting since his diagnosis in 1984). I have had my own heart issue (arrhythmia, PVCs–though I’m adopted and my parents’ issues are thus unrelated), and I will tell you that the state of the art in dealing with that is medieval at best albeit delivered with the same confidence as anything else.

I think it’s a human thing to want to believe we are competent and can handle what nature throws at us, that our technology is pretty damn good. When I read about, say, doctors in the 19th century, they seemed to have believed that they had pretty advanced knowledge of disease and effective means of treating it. Obviously, our technology today is vastly superior, but I think it will look quite primitive to what we have in 100, 150 years, and the confidence of doctors today will seem similarly naive.

Thanks for letting me rant a bit, and thanks in advance for relevant facts and opinions on the above!

2

I might be talking out of my ass (again, I know) but I think I read something somewhere, probably the internet (convincing so far, right?), that stents are both expensive AND still covered by insurance. So that’s the go to treatment. I’m happy to have this cynical view of medicine debunked, however.

3

I don’t know the answer, but I think it can take 15 years for new research to work its way into clinical practice.

I’m not sure what the modern clinical perspective on stents is.

Like it or not, there are also financial incentives in medicine. Things like scans and surgeries can make a lot of money for hospitals that may be losing money from other things like emergency rooms. So that is also a factor. Americans are more likely to get expensive scans as citizens in other wealthy nations for example.

Also modern medicine didn’t even really start until the middle of the 19th century with the discovery of germ theory and aseptic technique; the discovery of anaesthesia and advances in understanding of human physiology. On top of that, I think the (vast) majority of medical knowledge, surgeries and pharmaceuticals only were discovered post WW2. There are people walking around older than that.

In the grand scheme of things, you can make the argument that medicine is still a young science. Also the majority of the benefits in human life expectancy of the last 100 years come from public health (vaccinations, sanitation, water purification, seat belts, OSHA standards, etc) and not from individualized medicine (surgeries, pharmaceuticals, hospitals). Of course I’m sure individualized medicine has done a lot to increase quality of life and decrease disability.

4

My MIL had a stent put in under the Australian public health system last year, and there was no question about it not being simply the standard way things are done when your arteries are in a bad way (she takes medication too). So I’d hold off on blaming insurance issues until further data comes in

5

Yeah. My grandmother died at age 61 in 1977 after a heart attack, and they did very little for her. Open heart surgery was still new and quite risky, and catheterizations were just starting. So even in my lifetime we’ve gone from pretty much nothing to a lot.

6

I did a fair amount of research on this after I was hospitalized with a mild heart attack. The typical choice is not between stenting and medication, it’s between stenting (percutaneous coronary intervention, PCI) and bypass surgery, which is your classic open-heart surgery, with all the risks and after-effects you would expect – see this thread – and I admire the bravery of all those who went through it and wish them the best. Sometimes there is just no other option.

In my situation I was wheeled down from the hospital room to the catheter lab for an angiogram and possible PCI, and then wheeled right back after being told that I was not a suitable candidate for PCI. A short while later a heart surgeon came by and started talking to me about my upcoming bypass surgery.

I resisted and started pushing back and doing my own research. It turned out that the catheter lab in this hospital was doing advanced research and was engaged in field trials on things like fractional flow reserve (FFR) directed stent placement, meaning that blood pressure measurements could help optimize the placement of stents better than traditional methods. There’s been some evidence that advanced techniques like these and technologies like drug-eluting stents have brought PCI into the same long-term survival rates as bypass surgery without the risks and major recovery issues of bypass surgery, as PCI is a minimally invasive process that can even be done on an outpatient basis, though it requires some amazing advanced robotic equipment.

It’s no exaggeration to say that a major turning point in my life was when my cardiologist stopped by my hospital room one bright and sunny morning and announced that after meeting with all the appropriate medical staff, it had been agreed that PCI could be made to work for me, and instead of waiting for bypass surgery and suffering months of recovery, I’d get the procedure that very afternoon and be home the next day. After all the pent-up stress and emotion, I literally burst into tears.

7

Stents are so good that some people tried using them more-or-less prophylactically. To get you off the drugs and to protect you from dying later from a problem that might develop later. It turned out that didn’t really work well. It was better to just take the drugs.

Technology continues to develop. I don’t know what the state of the play is now. It’s still going to be the case that surgeons do surgery: if you go to a surgeon and ask what he/she can do, they’ll tell you about the surgery they can do. Apart from that they may not have much to say: doctors don’t always get into surgery because they like talking to patents.

8

Yes, my Dad died in 84 of heart problems that now have loads of possible treatments and surgeries that could likely have saved him if it had happened now. Kind of irritating, while also quite amazing how far we’ve come.

Though people still die of heart attacks that seem to come out of nowhere. Happened to an acquaintance of mine just a couple of months ago at only age 53.

9

I had a nephew who simply dropped dead at 30 (believed to be sudden arrhythmia). Heck, I have a nephew that went to bed for a nap one afternoon and didn’t wake up because his heart stopped. He was 24.

We have a LOT of heart disease in my family, and some of it starts young, in the 20’s in slim, fit people.

But, more specifically on topic - my limited understanding is that the research did not say stents were useless or inappropriate, just that they were not the panacea that some people thought they were. I haven’t studied the topic in detail in recent years but my guess is that when some stenting was found to be good interventional radiologists (because it ain’t surgeons installing these things) thought more would be better. That’s not how medicine works. And for patients, the limited pain and suffering and much shorter recovery time was no doubt very appealing, but that’s not what you should base treatment decisions on.

Yes, open procedures suck. I watch my mom go through two of them and refuse a third. (When she said she’d rather die than go through that again she meant it literally. Some of the doctors required convincing that she was not engaging in hyperbole but meant it) On the other hand, sometimes even today they are still necessary and the best treatment for a particular patient. If you apply stents when an open bypass is what’s really required you’re just adding unnecessary treatment to the problem and thereby increasing the chances of something going wrong.

And yes, docs talk like they’ve got The Answer. Think about it - you have to be insanely confident to poison someone to the point of unconsciousness, slice them open, stop their heart, re-arrange the plumbing, sew them back up, wake 'em up, and expect them to live which is basically open heart surgery without the euphemisms. However, medicine is not an exact science, every human being is individual (even identical twins diverge over time), and sometimes you can do everything right and still have stuff go wrong.

A lot of docs are bad at talking to lay people. The docs that do tend to be better, the ones in fields where they have to talk to their patients, tend to be looked down upon by docs like surgeons. Not all docs keep up with research the way they should. There are all sorts of other issues like financial incentives and whether you’re seen by someone with a radiology background (which makes stents more likely) or a surgeon (which makes surgery more likely).

But… based on what you’ve (the OP) told us it’s impossible to know whether your mom’s docs were simply doing what they were accustomed to doing, or if they did everything correctly with regard to our current knowledge but your mother’s results were not as good as hoped for.

10

Thanks for everyone’s contributions thus far. Good info and thoughts!

11

Small hijack, but in your extended family every young teen IS getting a screening EKG and echo, yes? That history screams prolonged QT, WPW, or familial cardiomyopathy until proven otherwise.

12

What are QT and WPW?

Regards,
Shodan

13
14

Among many doctors there is a feeling that even if medications work just as well as a stent or surgery that most patients will not take medications. Thus it is better to give them something that always works rather than something that will only work if the patient cooperates.

15

or they may take the drugs for a while but then stop when they feel better. That’s a problem with antibiotics, people don’t take all that is prescribed. So now most doctors make a point to tell you take the all of them even if you feel better.

16

You mean… is everyone who is still left alive getting screened? Yes. Which is why my 33 year old nephew recently got a defibrillator installed. We no longer have any young teens to worry about, and in fact I’m the last one alive untested at this point.

Because the rest of this may not interest everyone it’s under spoiler:

[spoiler]On my mom’s side we have familial hypercholesterolemia. My mother had it, as did half her siblings. I do know that I did not inherit it.

On my dad’s side we recently discovered the Desmoplakin gene for autosomal dominant arrhythmogenic right ventricular cardiomyopathy, and by recently I mean less than a year ago. All five of my living blood relatives are positive for the gene. This comes a bit late for one sister, as both of her children are now deceased (the nephews who died at 24 and 30, and it was the 30 year old that triggered the research that lead to finding the disease so no surprise his mom had it, too, even if she has not shown signs of heart problems until this past year). My other sister has known about her heart problems for years (she’s on her third defibrillator). Her son is the one who got his defibrillator recently. I’m not sure which way his sister is going to go on the matter. The gene apparently has incomplete penetrance and she may not be as affected. My dad, who of course had to have had the gene to pass it on to his kids, died at 87 of cancer without showing signs he had this variation so you can have it and live a long life and die of something else besides heart failure even without medical intervention. As I mentioned, one of my sisters has the gene but hasn’t shown any heart symptoms until nearly 60. Of course, as my-sister-the-doctor has pointed out, the first symptom of this might well be “suddenly drop dead without warning” (that nearly happened to her, she survived largely because her first incident happened while she was working in an ER). I have not been tested yet, being pre-occupied with a couple of other things in life. Because this gene is strongly associated with certain physical traits which I do not have it is unlikely I have it (though it’s possible, just much less likely) so I’m not feeling a sense of urgency about it, and I’m not entirely sure I want to know. I’m not going to have biological kids so I don’t have to worry about passing something like that on to someone else. There are certainly worse ways to go than simply not waking up one morning, or falling over dead in a quick manner.

We have had a little trouble with getting everyone an EKG and echocardiogram because apparently quite a few doctors are unaware of this gene variant and are reluctant to order such testing for someone not showing symptoms of heart problems, or who are “young and healthy” :rolleyes: Yeah, see, that’s one of the bastard things about this, it can kill people who are otherwise “young and healthy”.

The other thing messing with my head about this is, if I am found to not have this gene, then I stand a very good chance of outliving every single blood relative I have left, including those half my age. Can you have survivor’s guilt before you’re the sole survivor?[/spoiler]

17

Without going into far too much detail about the current state of research in stents, I just wanted to touch on a few points I think are important.
The study I believe the OP is referencing is the ORBITA trial (Lancet, 2018), which made headlines in the media but were largely wrong or missed the point. In summary of the results, they found that putting in stents vs maximally medically managing people with stable angina lead to essentially the same results, including increased ability to exercise on a treadmill. This doesn’t necessarily contradict prior research or guidelines, which essentially recommend that for stable angina medications and non-invasive treatments should be tried first. Unfortunately this was misrepresented as being the death of percutaneous coronary interventions like stents which lead to a lot of confusion among my patients.
That leads me to the second point. The general media likes to report studies that can generate big eyeball grabbing headlines. For better reporting on these, I’d suggest reading science minded media, but even that can be confusing, because…
Science is confusing. It’s pretty rare, if not outright impossible, that one study will upend prior knowledge to the point that everybody forgets what came before and reverses course. The more usual course is there will be a general trend and then hopefully a really well designed study will tip the scales over. Even then, though, who knows? As an example, a lot of prior bypass surgery studies were done 20+ years ago. A lot of the initial stent studies were done with 1st generation stents and technology has been steadily improving.
Anyway, just my two cents. I am a cardiologist, but obviously I’m not YOUR cardiologist, so none of this should be taken as medical advice, and all decisions should be made with a good informed discussion between patient and physician.

18

Who is this “you” that you speak of? In my view as a patient, and I think in the view of most progressive medical professionals, treatment decisions should be based on an informed collaboration between doctor and patient, because when there are different options, the choice is rarely black and white. I don’t claim that in my case PCI/stenting was necessarily objectively the best decision, but it was the best decision for me at the time for many complex reasons, and it was a decision made after a medical review by competent specialists. I was also, incidentally, told that medical management alone would not be an option in my case. So if PCI was ruled out, I was faced with all-out open-heart bypass surgery.

And that review would not even have occurred had I not insisted on it. Clearly I was a borderline case where opinions could differ as to which way to proceed, but one way had drastically greater risks and long-term recovery issues. Moreover, I was very gratified that the bypass surgeon was very frank about the recovery issues, and also very open to this informed collaboration idea. I don’t remember his exact words as he left, but they were basically that he would do everything he could to bring about the outcome I was looking for – and indeed, as it turned out, the medical team that reviewed the matter consisted of himself, my cardiologist, and the head of the catheter lab.

Somehow I missed this before. Yes, exactly what I’m saying, and that last part is just so important.

19

It was a very very generalized “you” and not a specific “you”. Once again, I wish English had a more nuanced 2nd person pronoun.

In your (specific you) particular case I do believe you when you say the situation was extensively evaluated to find the appropriate treatment for you (specific you).

In other cases other people may simply do what the first doctor they encounter says to do, or may balk at hearing the bad news that they need an open procedure rather than a stent. While it is the right of any competent adult to refuse any medical treatment, that should come after being fully informed of expected risks of both the treatment and not getting the treatment. Not all doctors (or nurses, or other medical personnel) are good at communicating with patients, and not all patients want actual communication. Clearly you (specific you) are not in that category.

20

One could make a habit of using “one”…