Acute Coronary Syndrome is a very dangerous situation. If a patient with this problem reaches a well-equipped and well-staffed hospital on time, a balloon angioplasty,  placement of a coronary stent or emergency bypass surgery can prevent a death, limit the size of heart muscle damage, and reduce complications of a heart attack. But what if a person is found to have some coronary artery disease (blockages in the arteries that supply blood and oxygen to the heart muscle and heart valves) but is considered “stable”.

Multiple studies have demonstrated that such stable patients do not benefit from having an angioplasty or having one or more stents placed in heart arteries that have partial blockages from plaque.  Despite the fact that over one dozen studies have demonstrated that stents placed in coronary arteries for patients with stable coronary artery disease do not prevent deaths, heart attacks or other problems associated with atherosclerosis, an estimated 50% of the 700,000 coronary stents placed each year in the US are placed in patients who have stable disease. Deaths Linked to Cardiac Stents Rise as Overuse Seen – Bloomberg

By 2012 the excessive utilization of angioplasty and stents had become such a large problem that Bill Boden MD, a cardiologist on the faculty of SUNY wrote an editorial in Archives of Internal Medicine titled Mounting Evidence for Lack of PCI Benefit in Stable Ischemic Heart Disease:What More Will It Take to Turn the Tide of Treatment?:  Comment on “Initial Coronary Stent Implantation With Medical Therapy vs Medical Therapy Alone for Stable Coronary Artery Disease”

In this editorial Dr. Boden explains that while angioplasty and/or placement of stents (Percutaneous Coronary Intervention) is beneficial for acute coronary syndrome, it has never been demonstrated to benefit patients with stable coronary artery disease compared with standard medical management.

Since that editorial was published a more recent review of the medical literature draws the same conclusion.

Cardiologists are paid an average $1,000 (range about $600 to $2500) for this procedure and hospitals and surgery centers receive about $25,000 for this procedure. If only half of the stents placed in patients with stable coronary disease are unnecessary the cost for the procedure alone amounts to $26,000 times 150,000 procedures per year in the US for stent placement. That is $390 million dollars a year in the US. If all of the stents placed in stable patients are unnecessary the direct cost totals $780 million per year.

But there is more cost than that. Patients who receive a stent must take potent blood thinning agents such as Plavix

Use of drugs like Plavix can result in costly and life threatening complications such as gastrointestinal bleeding (2% annually), cerebral hemorrhage resulting in stroke (0.1 to 0.4 % annually) severe drop in infection fighting white blood cells (1/2000) and other complications.

The placement of a coronary stent or performance of an angioplasty in a stable patient is also associated with complications that can result in death. What Are the Risks of Having a Stent? – NHLBI, NIH

So if you are not in the middle of a heart attack, what options are available to treat or prevent the complications of coronary artery disease? Optimal nutrition, exercise,  stress reduction and medications. This combination approach offers as much benefit with much less risk than having a coronary artery stent placed or an angioplasty performed.

Peace

Bob Hansen MD