In 2016 at age 62, I had an MI with 100% blockage of my LAD while traveling business. Because of unlucky circumstances, it was over 20 hours after the onset before I received 1 stent that saved my life. I was in the ICU for 5 days, with my severely damaged heart, an EF of 20% & heart failure.
Mine was an acute situation that is not being discussed by Dr. Carroll. I had no history of heart disease in my family. Despite having many of the classic warning signs of bad cardiac health (obese, apnea, borderline hypertensive, bad cholesterol numbers), I thought my “good genes” would protect me. Yeah, that was a smart call.
I realized that my stent would not stop the progression of my heart disease. If I kept living as before, I’d have another blockage, & with my already-damaged heart, I was a dead man. It scared the hell out of me & I changed my lifestyle completely. I changed my diet (I follow Ornish) & lost 55 lbs., got a new CPAP & use it religiously, always take me meds. I went through cardiac rehab & now go to a cardiac maintenance program. I also have a great medical team.
I don’t know if these changes will arrest the progression of my heart disease, but so far, they seem to be working. My medical tests look very good, & I am asymptomatic with my heart failure. My point is, that had I made these changes to my lifestyle some years earlier & been on a drug regimen, I suspect that medical therapy would have slowed or stopped the advance of my heart disease.
23
How about enhanced external counterpulsation therapy? EECP
5
All I know is that I had a heart event at 3AM in the morning when RVing in Wasilla, Alaska. Fortunately, we were parked close to a hospital by pure chance. I entered the emergency room, complained of chest pains, had an EKG, and was flown by helicopter within 30 minutes to a hospital in Anchorage and a cardiologist. After application of a stent that same morning, I was released the next day.
Now, over six years later, I am in excellent health at age 81, and live a vigorous, active lifestyle that includes bicycling, hiking, and kayaking all over the USA. With the assistance of statins and magnesium (magnesium citrate), I live and feel as if I am 60 years old. So...for me, stents may have saved my life. And, yes, for the most part I have switched to a plant based diet. But...who knows? Stents sure beat open heart surgery!
13
Two years after heart stents, no angina, no heart attacks, no anxiety of living with blockages in arteries. no by pass surgery required, no feeling of fatigue, no need to retire, no need to expect heart failure. Thanks to modern medicine people are living longer with better quality of life. Gratitude to the person who invented stents and to the cardiologists who inserted them and got the blood flowing unobstructed across the full length of the coronary arteries and their branches. Surgeons and cardiologists are my heroes not the the Hollywood actors and actresses, not the ball players who give their teams a win.
10
If only a stent procedure didn't also require a walletectomy...
11
I am forced to repeat my n = 1 anecdotal report from Sweden where the interventionists who do the stenting are on salary and therefore put stents in place because this is seen as beneficial.
Ten years ago an event left me with stunned myocardium, diagnosis made at Fletcher Allen, Burlington, VT. I had been referred there because I experienced discomfort every time I ran. My American doctor said, stress angina, get a cardiolite stress test. I did and the results were sent to Sweden.
There I was called in and as I lay under the imaging screen as an interventionist inserted a catheter I could see that LADA was severely constricted.
He put two stents in but had to end before putting a 3d in the circumflex also severely constricted.
A couple of months later the 3d stent was put in and my interventionist said, you can try skiing x country in about 7-10 days. I skied, no problem.
In the 10 years since I got those stents I have never experienced discomfort and am still running, if slowly and for a shorter distance, soon to be 86.
The procedure cost me next to nothing - Perhaps $20 USD each time I checked in. Before I had them put in my GP had me experiment with spraying sub-lingual nitro before running. Did not help.
I do not think one can argue that 10 years comfort can be a placebo effect.
Will try to find out if there are Swedish studies of stenting.
Only-NeverInSweden.blogspot.com
Dual citizen US SE
14
The word “stable” is EVERYWHERE in this piece. Coupled with the term “angina”, this means something’s very clear to anyone who has made it through medical school, never mind vast numbers in health professions. In brief: What was explored in these studies and reported here has NOTHING to do with most of the anecdotal experiences of commenters here, and shame on the physicians complaining here that this piece misrepresents anything. It is very, very clear. Defend the medical device industry at your peril (or grab the $ while still have time, depending on your ethics).
11
This is not the first article of its kind within the last few months, and since orbita, that the efficacy and ethics of coronary stents have been questioned and data poorly extrapolated to debunk what we know is a life saving therapy. Articles like these do nothing but instill a wild fear in the general public that interventional cardiologists themselves are a sham and medical professionals in the cardiovascular community are understudied and unethical. I agree with the author to one point-Patients should know what they’re paying for. When it comes to PCI, you are indeed paying for better outcomes than vs medical therapy alone in many situations beyond stable angina. This attack on PCI is a great disservice to those you think you’re trying to help.
9
Such a misleading article, and a clear distortion of data to advance the authors extreme point of view which is not accepted by anyone who actually takes care of cardiac patients. Stents are lifesaving in the setting of acute MI, the author totally ignores this well established fact. As a Physician who trained in the 70's when we could only watch as many MI patients went into cardiogenic shock with no way to relieve the blockage, it is miraculous as most patients with acute MI today are in the cath lab in less than an hour with the acute blockage opened and stented, minimizing heart damage, many back to work in a week.
As for angina the data is not as striking, but studies do show that stents provide immediate relief of angina pain whereas medication does not. The statistics the author touts were based on one study and how long they could exercise on the treadmill, not on whether they had pain or not. In addition the author ignores the fact that many patients cannot tolerate Statins or beta blockers which are the mainstay of medical therapy for angina. I had a single stent placed in 2015, as an active person on meds I was having exertionsl chest pain and my cath showed significant single vessel disease. I had pain biking, running, and walking the golf course. The day after the stent was placed I was totally pain free and have been so ever since. The pain relief is not placebo, other studies have clearly shown this but the author chose to ignore them.
17
My experience is very similar. I exercise regularly and started experiencing severe shortness of breath prior to my stent placement. It turned out I has 95% blockage in a left side cardiac artery. Stent placement instantaneously brought relief and was back to cycling a week later. I can believe stents may be over prescribed, and it's likely there's a placebo effect. I don't see a clear solution in the study results.
Diagnosing the problem is the opportune time to implant the stent. The converse as suggested by this study is to do the opposite: diagnose but don't necessarily treat with a stent unless otherwise warranted. What's the benefit here? Double surgeries, waiting, hoping. Give me a break, who wants that option, outcome, or expense.
It seems to me that what's warranted is a better diagnostic tool or better clot removing capabilities, and we're not there yet. That's the unfortunate reality.
6
There's another reason patients report improved health and less pain following stent insertion. For many, the event preceding the introduction of a stent is a frightening wake-up call. Following insertion, they may be motivated to lose weight, eat healthier, quite smoking... or any of a number of things they should have done anyway. The follow-up visits to the cardiologist help keep them on track. For the doctor, the patient by patient evidence is improved, same for the patient. It may have more to do with the lifestyle changes, than the stent, though.
7
Good point. In my field of spinal disorder, I think many surgerical outcomes look much better because patients are forced to stop engaging in aggravating activities while recovering from the surgery.
5
This is an extremely common thread in the medical world. Take for instance the *entire* practice of "interventional pain management". For common lower back injuries (or worse) you're forced through a series of very expensive interventions ... epidural steroid injections, followed by physical therapy, followed by microdiscectomy, and maybe even a fusion.
All of these interventions, the physical therapy included, have *zero* efficacy. Studies with patients doing absolutely nothing tend to fair better than intervention with risks including everything from total paralysis to death. The epidural steroid manufacturers have even begun to label the product as "not for epidural use" because the *experimental* procedure has 0 efficacy while offering patients *only* major risks: pain, paralysis, and death. New Zealand has outlawed the practice.
Doctors continue not only to offer these as possible experimental solutions for desperate patients, no they pretend like they are tried and true solutions that are safe for all.
There is this all natural and *actually* efficacious treatment for the patients with the worst, most debilitating pain called morphine. It costs pennies, but unfortunately we've prioritized the safety of addicts over the health, safety, and wellbeing of pain *patients*.
I don't know much of other medical avenues, but the fact that surgeons are cutting up patients' hearts for profit is upsetting, but hardly surprising given my experience with spinal cord injury.
4
Until all doctors are on salary with no bonus for production or anything else and no performance parameters or patient satisfaction considerations we are not going to have rational medical care. Honesty by doctors is not rewarded and is often punished. If only proven effective treatments were authorized we would have a significant surplus of doctors. Even more absurd we bring masses of doctors from third world environments that are in desperate need of medical care so they can do unnecessary treatment in the US. Since unnecessary surgeries and treatments6 have complications as well the overall quality of care continues to sink.
8
As an interventional cardiologist I have seen overuse of PCI (aka stents) first hand. This is what I do for a living. But the author here and many outlets have really demonstrated the misuse of statistics. The primary outcome for this study was NOT angina or chest pain. It was exercise time on a treadmill stress test. As a physician, the author should know better than to leave this important fact out. In other words, if you want to increase exercise capacity, a stent is not the answer - and this study clearly shows that. If a patient has stable angina, medical therapy and ‘stents’ are both good options and should be used wisely. Additionally, if symptoms are unstable or causing a myocardial infarction (aka a heart attack), PCI has been proven to be the better option vs medical therapy alone.
21
I’ll also add that my critique of this NYT article doesn’t extend to the ORBITA study it refers to. It’s a good trial and confirms what previous studies have shown as well- patients with stable angina are complex and improve with medical therapy alone, and stents are not a ‘magic bullet’. It sounds pretty dumb when Dr. Carroll distills it down to ‘stents are useless’ but hey, it sure gets more attention...
8
Well said. Thank you.
2
In response to inconvenient facts you will get random stories of miracle procedures, especially those that are expensive and dramatic. It is the human condition. Besides, there is a lot of money to be made with stents.
Look into arthroscopy for DJD as well as many other medical procedures. Then try to take them away from patients who are convinced there is a fountain of youth in those costly blunders. It is a tough sell. One of the reason medical care is so expensive, also much less personal than it used to be.
2
@ kirk Montana - it would help if every American comment writer would include the words in America after "expensive" or "money grubbing doctors".
My comment 6 or 7 above yours reports on experience from a UHC country, Sweden, where the interventionists who put my stents in were on salary. Nobody called me in so they could get richer. They called me in to take the next step after they got a report from my cardiolite stress test in Vermont where I happened to be.
Only-NeverInSweden.blogspot.com
2
The last paragraph in the article is the whole story. And those of us who practice according to the current paradigm of evidence-based medicine advise our patients exactly that way. However, many people (and many less responsible news writers) will read (or write) for a 5 second attention span and miss the whole story. Stents have been proven to prevent major adverse cardiac events ("MACE") in patients with an acute heart attack, additional severe multi vessel disease after an emergency intervention for a heart attack, unstable angina, in patients with ongoing angina on optimal medical therapy, and additional important subsets. We have to inform our patients as to what is known about risk and benefit. Often it involves debunking a story they thought was their story but is actually more specific.
9
"knowing what they're paying for"? In addition to a doctor being incentivised to place the stent, the patient is insulated from the cost. Add that to the current mythology and the placebo benefited friends and neighbors and what do you have? Ineffective bad medicine.
3
This article doesn't explain whether and under what circumstances stents are ever effective.
5
That’s a great question- but those indications would undermine the authors assertion that ‘stents’ are placebos. Acute myocardial infarctions, and most unstable chest pain symptoms are clear indications for percutaneous coronary intervention (PCI). Like any treatment, PCI is not a panacea but it is also not a placebo.
8
You need to read the article itself. The patients were all stable and in that case it seems you can opt not to have a stent.."Exclusion criteria were angiographic stenosis greater than or equal to 50% in a non-target vessel, acute coronary syndrome, previous coronary artery bypass graft surgery, left main stem coronary disease, contraindications to drug-eluting stents, chronic total coronary occlusion, severe valvular disease, severe left ventricular systolic impairment, moderate-to-severe pulmonary hypertension, life expectancy less than 2 years, and inability to give consent. "
2
I have four stents. I have coronary artery disease. I do not have angina. Two stents were placed after a heart attack caused by blocked arteries. One of the two stents blocked up. The doctors unblocked it. Then two months later I had two more stents put in. I m fine now and on some meds . This saved my life. I would have died had the arteries not been unblocked. I watched the entire procedure each time I was in the cath lab. This article is a huge disservice to cardiac patients. Shane on you and by the way it is national heart month. Time to raise awareness not spread superficial misinformation.
8
Your experience is what is referred to as anecdotal. You have misread the article and misunderstood the recommendations.
7
Same reason as people put plastic protectors on sapphire phone screens and don't understand it's like protecting a battleship with papier mache.
1
Alas, one need look no further than the overwhelming majority of these comments to see what massive hurdles exist to evidence-based health care. Not to mention a stable, affordable health care system.
Or a reasonably widespread understanding of statistics amongst the population.
Or critical thinking ability in more than a tiny fraction.
6
@ TG MA - I think you should read the comments more carefully. Perhaps you could also tell us how you arrived at your conclusion - overwhelming majority.
The hurdles to be cleared if we are to have evidence-based universal health care are not the fault of commenters but rather the fault of the two major political parties, especially the Republican party.
Only-NeverInSweden.blogspot.com
2
As a daugther of a woman that recently passed away from "Congestive Heart Failure" I came to learn that anyone with a blocked artery should get treatement before it gets late. Sadly for my mother it was too late sa she didn't believe in stents or anything else until she had to have a open-heart CABAGE. Then they called her CHF. I was so uneducated that I had to ask what CHF meant. What CHF is "cancer of the heart" - this is a polite way of telling a patient and their family that there is nothing one can do anymore but to slow down the progression. For us sadly it was an extremely painful 8 months. A stent would have helped save her life. Problem was that she was a chronic smoker, had asthma among many other issues. We would never know what may or may not have happened.
Since her brothers all have passed away of similar issues - I know there is a chance I could develop this too. But to share this thought is that a lot of success of any heart issue has to ALSO do with the healthiness of our blood. As someone wrote brilliantly before, she changed her diet. That truly makes a difference in health of our blood. Whether it is our INR or anything else. I wish we were educated sooner. A stent would have been possible years before and we would have avoided te painful "Open Heart" surgery, rehab and all the complications after. This article is very misleading. I wish it was more data driven than this one. Best of luck to all of you with heart problems.
3
You are aware that the single proven, reliable way to extend your mother's life was smoking cessation? The stent would have had a very slim chance, at best, of giving benefits anywhere near as good as quitting smoking.
4
Just as modern artificial intelligence has recently shown humans the errors in their way of playing chess (although a human has not beaten a computer in chess for 20 years), it will show humans the errors in their conduct of medicine. And the change will be abrupt. That there is a ton of money and professional reputation standing in the way of progress will not delay the revolution by very much at all. Five years is exponentially becoming a longer and longer time.
4
I'm thinking the rubbing at the beginning of the article may be more than a placebo. The rubbing may be stimulating the release of natural pain-killing chemicals ( endorphins) from the brain.
Having seen the before and after images of the placement of the stent in my husbands artery I could not disagree more with your demeaning of the procedure. He watched on the monitor as it was inserted. His artery went from a pencil thin line to 3/16” minimum. Instantly. He felt better instantly. I would say the procedure was well worth it as would any sane person. If you saw the images, taken during all stent procedures, you might have a different opinion.
12
I have stents. I needed them. However, as the article points out, medication seems to work as well as stents do with people who have stable angina.
So it's possible your husband could have improved just as dramatically, if not as fast, without the potential risks that accompany the procedure. And there's a risk from simply being in the hospital of becoming ill.
2
"as would any sane person": this is in fact an uncivil personal attack. Psychological intimidation/verbal abuse?
Also nice scope shift from the population level--where effectiveness can be proven--to the anecdotal, unscientific account you provide.
2
And, a pencil has been proven to be, on average, 3/16" thick.
This article should be rewritten to make clear that stents used to open arteries with emergency blockages are immediate lifesavers. It sounds very much as though all stents are being given a thumbs-down.
29
Studies published in the New England Journal of Medicine and elsewhere show that the placebo effect does not exist. Giving people sham treatment or fake pills (placebos) does not make patients feel better. It is no different than doing nothing for the patients.
The placebo effect is a misinterpretation of data. The researchers who thought they saw this effect forgot to compare the placebo group to a group that gets sent home with no treatment at all. What they were seeing is that many patients get better on their own.
See:
http://www.nejm.org/doi/full/10.1056/NEJM200105243442106
http://abcnews.go.com/Health/story?id=117429
5
Studying for an MPH degree in a major medical university in 1986, we were taught that 'outcome management' studies for medical procedures didn't exist and most certainly should be implemented. More than 30 years later, nothing has changed.
There is no financial incentive for research proving that a profitable product and expensive medical procedure does not work.
Capitalism provides sub-par healthcare.
11
Had a PCI in 2009 after significant angina on exertion and perfusion study suggested near 100% block in LCX confirmed on catheterization. Able to exercise regularly and vigorously without pain after, which obviously has its own cardio benefits.
Placebo? Perfusion study suggested I was at high risk for a "hard event" and soon. I'm still here and doing well about ten years later. I suppose survival also has a placebo effect.
12
What this shows is that when there is an approved protocol doctors stick with it, no matter what evidence comes later. Confirmation bias other rationalizations keep them doing what they always did. It is also true that newer, better procedures and medications are not used because after all, the current protocol works just fine.
9
Decision making either by health providers, or by patients, in regards to health and choices of treatment, does not take a beeline. Such decision making may often be irrational, if one defines rationality as adherence to evidence. In other words, medical decisions are often not evidence-based, as much as how much we would like them to be.
Evidence-guided decision making can be counter-intuitive. Intuition would tell a patient that a treatment with more intervention, such as opening up a blocked heart artery, is superior to a treatment with less intervention, such as taking medications.
In this case, as in others, intuition is also informed by the societal acceptance of common beliefs.
In as much as the pervasive idea of "more intervention is better treatment" influences the health-seeking behavior of a patient, it also sways the decision making thought process of a physician. After all, by choosing the treatment with more intervention, the physician feels more secure, falsely no doubt, that "everything that can be done has been done" for the patient.
Applying evidence to medical practice is not simply an intellectual exercise of the medical profession; the success of evidence-based medicine depends on the full acceptance of evidence-based knowledge by the medical profession, other health providers, patients, and the society in which we live.
5
I do not think this article has any place on the front page of the nation's "paper of record." The headline is pure click bait. And the tone of the article is hardly dispassionate. Stents have a place in medicine. They are not "often useless" and they certainly have improved the lived experience of hundreds of thousands of men and women. Are they over used. No doubt. Are they expensive. No doubt.
12
How do you know they "certainly have improved the lived experience"? If that were the case, why have objective experiments failed to show any improvement? You are asserting something that is contrary to the only scientific evidence now available. Can you point to a study that supports your claim? If you cannot, then you have no basis to say this. It is not a matter of opinion; it is a matter of fact.
6
hey jed, no one who knows the literature would suggest that stents have no role in medicine; this study indicates that they are being used when don't need to be, that's not the same as showing they have no proven utility. perhaps you should read the article again, it's full of disclaimers that this study applies to certain clinical states, not all states. and in response to some the other comments, medicine has shifted towards evidence based approaches in a major way, and I'm sorry but artificial intelligence won't be solving these medical problems for an awfully long time if ever....
6
My MI occurred in 2007. I was completing a phone call to a colleague regarding a mutual patient. I recall feeling doubtful that I could accomplish the hope held out by my colleague who was a psychiatrist.I was aware of feeling deep concern. The case rang remarkably similar to my own relationship with my mother's mental health issues when I was a child. In this replay of a helpless childhood event,I felt a rush of heat ascend to my jaw, labored breathing, and felt quite unwell.I ended the call, said to myself, Good grief, I think I'm having a heart attack, and called 911 - and the rest is history.
I was given a stent in my LAD without further ado and after an overnight in the hospital was sent home with a slew of drugs, including Warfarin, Plavix, Coreg, Lipitor, and a medicine that has since been taken off the market for Gerd, which I never had.
For many weeks I had to get my INR levels checked and cut back my love of brocolli.I had excellent cholesterol numbers.
I searched for a cardiologist who would level with me about the whole episode and discovered that my troponin levels in the hospital never had gone higher that 4.5 and that my ejection factor three weeks later was 69 or the high end of normal. I'm not a cardiologist, but question the stenting. I think I had a panic attack. I no longer take statins, BP meds, or blood thinners.My EKG's are normal. Yet, I'm sporting a stent - all because they were popular in 2007 and I didn't know enough to refuse.
6
It sounds like you suffered a heart attack. Your troponin of 4.5 confirms myocardial injury. It is probable that your EF is normal because the stent prevented your artery from entirely occluding and loss of muscle tissue.
Again, the study in question was looking at stents in chronic stable angina patients, not acute cardiac events. Different diagnosis.
9
Your ejection action should be normal after a heart attack - and it wouldn't take weeks - assuming you were stents fast enough to block permanent damage to your heart.
I had a heart attack. I received a staent. My ejection fraction rate was half of normal after the procedure. The next day it was low normal. And some weeks later it was normal.
So your high normal reading is not indicative that you didn't have a heart attack.
1
Your logic is backwards and Im suprised you found a cardiologist to agree- your troponin level confirms you had a true myocardial infarction. If you hadn’t had a stent to the LAD it would have gone higher and your ejection fraction would not be normal. That’s the paradox of good treatment- when it goes well people wonder if they really needed it in the first place. A troponin level of 4.5 is significantly elevated.
4
Let's be blunt: people will die because of this article. People who truly need stents or bypass surgery may think that their cardiologists are being venal to suggest that stents are needed to prevent serious consequences if they believe this writer. If the article plants a seed of doubt about the net value of stents, it has done a disservice to the community and to individuals who are encouraged to just tough-out the pain rather than to seek medical help.
The problem, if there is one, is the misinterpretation of a journal article by a reporter who should know better. If you don't need stents, you shouldn't get them. If you don't trust the cardiologist who recommends that you need a stent, find a better doctor before you get a stent. But, for goodness sakes, don't liken stents to moisturizer!
The problem is that this article conflates those with random chest pains with those who have serious cardiac problems. Those who have had heart attacks and have, for example, 90% occlusion of one or more arteries, need stents or bypass for survival, period. Why not start the article with the observation that stents do save lives in those that need them? Likening stents to moisturizer is an atrociously misleading statement.
30
shoot the messenger much? Not able to attack the science head on?
So many of the people answering who have stents with their anecdotal stories are not paying attention to the details of the article: stable patients with one vessel disease is not the same as 'my CABG vessels were all blocked' or 'first MI at 43' etc. The article even states that there is a place for stents just not as many as we currently do.
I recall watching a piece filmed at Mayo Clinic years ago that stated the same thing.
Pity that even the MD patients cannot see through their own myopic point of view.
14
I think the NYTs lost a lot of credibility in my eyes on this story. I am a noninvasive cardiologist and hence have no stock per se in interventional procedures. The author of the article was very strong in his criticism of cardiac stents for stable angina based on a very small study involving about 200 patients. There were many exclusion criteria prior to randomization in the study and some patients received stents anyway after being randomized to placebo(intention to treat). A study like this should be used for hypothesis building and lead to other larger studies. It is still best for the patient's cardiologist to make treatment decisions with the patient keeping their specific situation in mind rather than adhering to dogmatic principles such as stenting for stable angina is inappropriate. I fear that an article like this exposed to a public with a limited knowledge base could cause more harm than good. Frankly as a result of this article I have a more "jaundiced eye" to the veracity of other Times articles on politics and other areas where I am not the expert and must rely on balanced reporting of the issue
23
You lost me with your "jaundiced eye" comment. The article was clear about everything (except it didn't define "stable angina).
Re-read the article, which states that people with the more common, non-life threatening angina who have either drugs or angioplasty have the same number of heart attacks and death rates.
Even if the article doesn't state the above, you're making quite a leap to think that because one article you think has false claims mean that all articles on all subjects in the NYT hit offer false claims.
How ironic and confusing: you insinuate that the author proposes inappropriate "dogmatic principles" when clearly the author is potentially exploding them.
this is an absolutely brilliant response. and it's true that when the media and even the Times writes about something that we are experts on we find fundamental flaws and errors, which indeed makes one doubt the veracity of all reporting. for a great analysis of this issue I'd recommend Steven Pinker's article about malcom gladwell, he nails the whole pseudo expertise problem that journalists propagate.
3
I have had by pass 3 times and stents 3times. Started in 1983. I am now 70. My cardiologist since 1983 has stressed (bad choce of words) that medical and intervention work hand in hand. Dr. Carroll should take up my choice of professions, attorney at law: all stories have two sides, the plaintiff and the defendant’s.
3
It is my understanding that heart stents are placed to eliminate blockages and preempt heart attacks or if there is a heart attack to open up blockages. A lot of the times they are an alternative to going under the knife for an invasive bypass surgery which is much more expensive and takes longer to recover. I don't understand what Aaron Carroll is trying to say that heart stents are useless for most stable patients. The insurance has criteria for what percent blockages they will cover for inserting stents. Placebo effect. Really? I hope Aaron Carroll knows what he is talking about before making bold statements.
5
The article deals with stable angina. Stable patients aren't in life-threatening situations. That's why its called stable angina.
The article also states that stents are sometimes necessary, when stable angina isn't in play.
6
You want unplugged arteries? Take therapeutic--repeat therapeutic--levels of vitamin C and watch your arteries clear. Better yet--don't let them clog up in the first place.
I come from a strong familial history of heart disease. My grandma's twin died at birth. Her sister died at 42. She died at 66. My grandfather died at 56. My mother retired on disability in her early 60s because of acute angina (died at 87 of medical mistakes). Until a new grandchild disrupted a miserable sedentary lifestyle glued to her comfy chair, she could hardly walk without getting out of breath. Being happy and busy added more than two decades to her life.
I am 68. I have perfectly clear arteries. I take no prescription drugs. I enjoy full-fat dairy products and occasional meat; I eat plenty of high-fiber plant-based foods too. I take between 6,000-12,000 mgs. of vitamin C daily, depending on my diligence. Genes are not necessarily destiny.
1
Just out of curiosity, what meds are given to heart patients that (allegedly) work as well as the stents? Are they statins?
2
Exercise and healthy food is one prescription. Medications like aspirin and plavix thin the blood and help keep blood clots from forming in the heart's arteries. Blood pressure medication, beta blockers to slow the heart beat rate might also be prescribed. An yes, statins, to have been shown to be effective, with or without stents.
In fact, al of the above are potentially helpful with or without a stent, which is the point of the article about people who have stable angina.
2
Not statins. These alter the concentrations of lipids (fats) in your bloodstream toward reducing the process of atherosclerosis.
Nitrates, calcium channel blockers, some beta blockers, others, and combos. These increase blood flow to heart muscle and/or reduce the work that the heart does to pump blood.
See NIH/NHLBI or Mayo Clinic web sites for information for lay people. Use coronary artery disease, angina as search terms. By reading these, you will be better equipped to discuss with an MD if the need arises. And you won’t rely on anecdotal experience - like so many of the commenters here.
I recently asked my new cardiologist for a stress test. Ten years prior thereto I had two heart attacks, treated with stents. The cardiologist, with knowledge of my history, refused the test citing a study by a special panel of eighteen doctors who asserted that a stress test was not predictive of heart attacks. My conclusion was that the insurance industry had purchased the eighteen doctors opinion. The cardiologist was affiliated with a major university which received money from the insurance industry. I believe the cardiologist did not base his refusal on long established medical acumen but his desire to line his pockets and those of the university.
In my opinion the doctor's who published the stent data in the distinguished medical journals were also receiving direct or indirect financial benefit from the health insurance industry. A detailed examination of the doctors funding for their studies as well the organizations they are affiliated with would probably reveal significant conflicts of interest.
1
if you remained symptom free (no chest pain or shortness of breath)with no changes in EKG after 10 years,your cardiologist made the right recommendation;unfortunately physicians get blamed frequently if they do not dance to the tune of their patients!
10
You envision a conspiracy in which insurance companies pay doctors or universities not to do tests. How large a conspiracy would that have to be? How is it possible that no one has broken, or filed a Qui tam suit?
4
There is a high rate of false positives with stress tests.
1
The study this article refers to gives real food for thought. Clearly, there may be a genuine placebo effect. Further study will be needed. My only criticism is the follow up period was only 6 weeks. In my opinion, that simply isn't long enough to draw conclusions. We need to see how the placebo group and stent group did at 1 year, 2 years, etc.
For those of you who are swearing by your stents, I'm glad you're happy with your outcomes. But statistical analysis is what is needed to draw strong conclusions and a series of case reports is a type of anecdotal evidence which is worthless.
Also, remember acute blockage of coronary arteries requires stenting and is life-saving. For people with exertional chest pain, known as angina, the blockage has built up chronically over time. It is this population that we are referring to here in this study, and in my mind, the jury is out on this. Stenting these lesions may or may not offer benefit- and certainly carries risks and much expense.
Emergency Medicine and Internal Medicine- Board Certified, in practice 24 years.
4
Why? Reimbursement for interventional cardiologists. No placebo effect there.
5
This is an incredibly irresponsible article. I had two angioplasties at age After the second one in less than a year, I had three cardiac stents placed in one of the three major arteries supplying my heart. I am now 67 and have never had another attack of acute angina since. Needless to say, I have never had an actual heart attack ever.
I was given pictures of my coronary artery after the stent procedure. Before it was dessicated and collapsing in on itself. It's a wonder any blood could get through it. After? It was like the Alaskan pipeline. I have had a thallium stress test every two years since my procedure. I have taken statins since that time and other heart healthy agents like fish oil. My arteries remain open, unblocked and flowing.
To say the stents were mere placebo is a joke. I have no doubt I would be dead by now had I not had this intervention. Statistics and meta studies used at the behest of the insurance industry to save them money by saying life saving interventions are mere placebos amounts to malpractice in my book. You can make the data reach his conclusion but it is a lie; it's not reality. Cardiac stents saved my life. Period full stop. This is not a nuanced reading of the data, but a reading with an agenda: denial of cardiac care.
11
IntheFray, yes, it may indeed have saved your life, but one case can only provide anecdotal evidence--meaning your experience, as good as it was, does not scientifically represent what the average stent patient experiences. This reality (and this very well-written article) does not deny that particular individuals with particular health issues may actually benefit from stent placement. However, in general, too many stents are being used in individuals who are not benefiting from them.
6
I also had three stents placed in my heart 15 years ago due to acute angina. I have not had an incident since and my heart and overall health has been perfect. I believe this article is irresponsible, based on my experience.
8
Did it ever occur to you that you might have done has well without the stents since you started statins and lifestyle changes?
Beware a conclusion based on an N of one (you alone).
Paranoia regarding the greed of the healthcare industry is well founded, including organized interventional cardiology, the one who live off the stent placements.
"The problem was that it was difficult to know whether the stents were leading to pain relief, or whether it was the placebo effect."
- Doctor, do you REALLY believe that? I am one week post-angioplasty. Both my 15-y-o bypasses were 100% kaput. I had had two near-misses in the previous week. My TIMI score was 4 and my Grace score 100.
Now that the cardiologist opened the (blocked) circumflex artery and stented it, I have no angina. My blood pressure has dropped from 140/60 to 110/70 with minimal medication. I'm going back in a week to commence full rehabilitation.
- Oh. Perhaps I forgot to mention one thing: I am a member of the single-payer Mexican national health system, and all this dedicated attention has cost me precisely: NOTHING.
With thanks to the dedicated staff of UAME 34.
6
These articles are excellent by this Physician . With that said, most patients follow their specialist, recommendations. My individual research, by many noted Physicians, in a great book, titled," ending medical reversals", points out, most of what the medical profession prescribed, is based on," this should work", not trials.
2
Seems like a lot of readers are getting hung up over the issue of acute vs chronic heart disease. What the study and this author address is chronic heart blockages. It's clear in that situation that stents have no benefit beyond placebo.
What readers are up in arms about is acute blockages, such as heart attacks or unstable angina. This article/study does not address that situation.
So, for slowly developing blockages, stick with medications and lifestyle changes. For sudden blockages leading to acute, life threatening symptoms, get to the ER immediately, and don't worry if you end up with a stent.
25
This article is silly beyond belief. Stents are not placebos except if they were not needed in the first place. The article is dangerously misleading.
8
Bad genes, worse family history and I had my first hear attack at 43. Two stents put in at that time and I ran 9 Marathons after. Had my second heart attack at 57 and another 4 stents put in then, in October of 2016. One was poorly placed and I had increasing shortness of breath for well over a year and then near daily angina attacks until I collapsed in Penn Station in early December. EMS took me to Lenox Hill hospital where the poorly placed stent was corrected by putting another inside of it, along with another two. I have nine total now at 58 years old and finally am starting to feel better for the first time since October of 2016. I am out on disability now, but alive and here for my wife and children. Don't tell me stents don't save lives because that's just a bunch of baloney. I'm proof that they work when they're done properly and in the right patient.-Dr. Andrew Forelli
8
I am a heart patient but also a little bit of a medical agnostic. Had 3 stents placed to alleviate arterial blockage that precipitated heart attack.. Symptom improvement followed immediately.
Following procedure to place stents:
Angina from exercise no longer present.
Endurance before cardiac rehab had already increased.
Showed some improvement in fluid retention reduction in area around ankles.
Blood pressure went down immediately and is well within a normal healthy range.
Heart (pulse) rate immediately following procedure was below 50 quite consistently and persisted at that without medication targeting blood pressure.
All resting residual chest pain is gone for now.
Am convinced that blood flow to all extremities is better.
Best part is that I walked in to have procedure one day, and walked out and drove myself home the next day.
My biggest worry now is that the improvement gains I perceive may recede over time. We will have to wait and see. I think a lot will depend on life-style regimen I adopt and stick to in the long run. But as my doctor pointed out, improving vital blood flow without open surgery certainly seems like good alternative.
4
Anyone following Dean Ornish's career would know it's the $$ going to the hospital wing, not science that's driving these decisions and perceptions.
4
Corruption in medicine by the insurance industry.
Dangerously simplistic! I have a stent in my left anterior descending artery. The angiogram taken prior to the angioplasty in which the stent was inserted showed a 90-95% blockage. I saw the before and after images - the increased blood flow in this crucial artery was dramatic. It has been four years since the procedure and I have not experienced any chest pain or shortness of breath since.
My quality of life is dramatically improved, but more important is the simple fact that without the stent I would undoubtedly have suffered a fatal in the interim.
I am alive because of my stent!
16
"It's possible that many procedures aren't better than shams." Come on, Dr. Carroll, show some courage in your conviction. I bet you can name a dozen dubious procedures immediately.
Human nature being what it is, it is probable, to the point of near certainty, that many procedures aren't better than shams. You surely know that most knee replacements are no better than rest and physical therapy. Why no mention of that, or deviated septum surgery, which patient outcome studies also indicate is a waste of money for everyone but the surgeons and their hospitals?
As for medical therapy, the evidence is weak to nonexistent for many commonly prescribed medications.
However, thanks, Dr. Carroll, for highlighting two facts that good health care policy must address: the rot of the profit motive, and the healing power of the placebo effect.
2
I meant to say most arthroscopic knee surgery, not total replacement.
1
The biggest problem with stenting is that it may fool one into thinking that blood vessel blockage is the main reason for the impending situation, as the cardiologist is the first person referred to in the chain and he has many diagnostic tools at his disposal. For elderly care, the cause of the problem may be elsewhere and may be missed altogether as it happened in my mother's context.
1
I had a heart attack. The overriding symptom was that I could not breathe. If the EMT had told me, "Ma'am, we can't do anything so you can breathe, but we can put you out of your misery," I would have welcomed death. An echo cardiogram at the hospital showed 4 plugged arteries. A cardiologist put in 4 stents. I could breathe. I went home 5 days later, worked a full week from home the following week, then was back on the job full time. I have been well since then, 6 years ago. If I had it to do over, I would not change a thing.
12
Just like the aortic valve replacement surgery they wanted my 89 year old mother to have, would give her 2-5 years... She had 2 1/2 years without, saving Medicare $100,000+....
1
Doctors and hospitals are not going to give up a money-making procedure anytime soon. The patients may have read about a study touting stents but never the follow-up debunking them. Patients and doctors don't like to give up what they were taught to believe. Several examples: mammography doesn't extend survival, women don't need pap tests every year, a PSA test is not a good screening procedure for most men and stents don't improve patient outcome in most cases.
2
Whoa. That's a lot of assertions lobbed in at the end. Mammography probably does not benefit women under 50, but probably does benefit women over 50.
PSA tests probably are not helpful. I agree. Certain women should probably have an annual Pap- depending on risk profile. Some women can probably safely have this exam less frequently.
So what is the medical therapy for this condition?
1
with a heart attack in progress surely a stent to open the offending artery is a proper procedure.
6
http://www.abc.net.au/news/2017-08-14/surgical-mesh-maker-used-fast-cars...
‘Lamborghinis and ski trips to the Swiss Alps were among the incentives a pharmaceutical giant developed to market a surgical device that has ruined the lives of hundreds of Australian women.’
Only agree to have a foreign body implanted in your body as an absolute last resort, when there really seems to be no other medical choice.
Stents are made from mesh. The Australian Senate has been hearing from thousands of Australian women whose lives have been ruined by greedy surgical gynaecologists who persuaded these unfortunate women to have mesh implants, manufactured by Johnson and Johnson.
3
No. Mesh used for pelvic surgery is made out of other materials. Cardiac Stents are titanium, cobalt alloy or a new biodegradable dissolvable material. Also, different organ system, different part of the anatomy, different purpose... Can't compare to Australian pelvic surgery situation.
3
So....maybe Australian style single payer isn't all it is cracked up to be.
Isn't it Australia and the UK with their failing NHS that are always held up as examples of perfection so much better than the USA?
How nice to have the good pediatrician bamboozle public and willing liberal readers of NY times about matters on which he has little training and education. Before claiming most of stents are unnecessary based on a single ill-designed study full of caveats, and that too in cash strapped and failing NHS of UK, he should at least provide numbers: what percentage of stents placed in US are in rigorously medically treated stable angina patients?
6
In the early 60s, the AMA was adamantly against testing new drugs for efficacy (see Kefauver-Harris Amendment) with FDA approval in the balance. They "knew" which of the 3,400 marketed drugs worked and double-blinded testing was "unethical" in their opinion. Over 600 of those drugs are now off the market due to lack of efficacy. Giving false hope to desperate patients based on junk science is unethical. It's high time to consider placebo/sham controls for surgical procedures.
2
What is/was the medical therapy done before the stents were inserted?
2
Aggressive blood pressure lowering, aggressive cholesterol lowering, use of Beta Blockers and antiplatelet medicine such as Aspirin. Also smoking cessation if you smoke.
Good evening ,
The article was interesting but would have been more helpful and informative if it had explained what “stable coronary artery disease” means and what is “medical therapy.“
Thanks.
4
Curious, I thought one major use of stents was to reinforce an aortic aneurysm to keep it from rupturing by taking the blood pressure off the aortic wall and putting it on the prosthesis instead, but what do I know?
4
I have the same question. And, should this procedure be done before the aneurysm gets to the critical point?
Similar, but not the same. A coronary stent is a small stent to prop open a blocked artery in the heart. You are referring to a different type of stent- an intraortic stent- a much larger stent designed to wall off an expanding aortic aneurysm to prevent leakage/rupture.
Those are 2 completely different devices.
Coronary artery stents are 0.2 to 0.4 cm in diameter and about 0.6 cm long. Stents that are placed in the abdominal aorta are about 2.5 cm in diameter and 10 cm long or longer. Stents placed in the abdominal aorta are also covered with a dacron fabric.
The 2 devices have some materials in common, but that’s about it
I received two stents in 2008. I could not walk across the hospital parking lot without becoming out of breath and experiencing chest discomfort. This condition had suddenly commenced a fortnight earlier. Immediately since the insertion, I have not again experienced anything close to that episode.
I am not disputing the studies, but I do not have a great deal of faith in the medical community, and I am not by nature given to imagining relief. However it is obvious that my circulation has improved. You can believe me or dismiss what I say.
8
The placebo effect can have a real medical effect.
2
The question is: Why are doctors using stents and medicines that alleviate symptoms but not causes of heart disease when it is so effectively prevented and reversed with diet of unprocessed fruits, vegetables, nuts, grains and legumes with no salt, added oil or sugar? Proper nutrition has been shown again and again to eliminate heart disease, high blood pressure, diabetes, obesity, and auto-immune diseases such as arthritis, symptoms of MS and more by Drs. Fuhrman, Esselstyne and others.
Rather than spend $10,000 on a stent and many more thousands on medicines over the span of the illness, why not spend a few thousands for each patient to attend a residential nutrition and lifestyle 'boot camp'. They could eat the diet that have proved effective in reversing coronary heart disease and receive instruction in exercise, yoga, meditation (the American Heart Association gives A+ rating to Transcendental Meditation for its medical effects) - and learn how to make the diet delicious and doable in a busy lifestyle.
This would save money, save lives, and more importantly provide patients with a much higher quality of life into old age.
8
I don't think the problem is lack of education (for many, maybe even most) but in simply having the self control to eat right and exercise. To people who do not have weight control issues this seems so straight forward.
1
Not disagreeing, but the age at which a lot of these problems show up is also an age where people don't change easily. I have senior parents, believe me.
2
"when it is so effectively prevented and reversed with diet of unprocessed fruits, vegetables, nuts, grains and legumes with no salt, added oil or sugar? "
Quackery. Heart disease occurs irrespective of eating a great diet. Vegans get heart disease - my cardiologist told me that most cases are genetic.
4
I've just finished reading a remarkably cogent new book, published in late 2017, that addresses the placebo effect and why it is effective in so many different areas of health. The book is deeply researched and highly elucidating; not only is it scholarly, but it is also fun to read. I recommend it without reserve.
"Suggestible You", by science writer Erik Vance, expands enormously on Aaron Carroll's excellent article.
http://www.mexicocooks.typepad.com
3
I had a "small" heart attack due to a blocked artery. A stent was inserted and I can tell you, I was back to normal three days later. I have no doubt that the stent did its intended job. Thank you Dr. Cardiologist.
11
Many other people with the same problem as you, but never had a stent put in, also did well.
Thank you Placebo.
That's what I learned from this article.
1
But NYT would rather people over 55 have a heart attack and die. That's why they published this column.
4
Probably many who didn't have the stent died. Why are you against the maximum protection if it may save a life?
Great article on a subject that is virtually unknown in US. This is just one of many like surgeries. I would recommend anyone interested in this subject please read Surgery: the Ultimate Placebo by Ian Harris.
2
I don't know if the stents I received will prolong my life, but now I can walk farther than 10 feet without having to stop to rest for several minutes.
7
Exactly -- same for me
1
This article does not discuss the cases where stents are of benefit. It would be helpful if the non-beneficial and the beneficial presentations were compared.
7
The article dealt only with non-life threatening conditions. Where imminent loss of life is involved, stents are called for.
The purpose of stents is to improve blood flow through the arteries. This blood flow can be measured. The reduction of secondary effects such as pain is not a good indicator of utility.
If the study reported here is intended to suggest that blood flow through coronary arteries is not a good measure of likelihood of a heart attack, then the researchers should try to make that case. I haven't seen it in this article.
It may well be that employment of stents to relieve pain is not a good procedure. Perhaps cardiologists have overused the procedure for this symptom.
14
They did a meta analysis showing that the death rates were the same earlier, according to the article.
"They should at least know what they’re paying for." In most cases they aren't paying anything substantial, maybe that's part of the problem in making this decision.
5
Of you have a useless medical procedure you pay for it. You may not pay in money but you pay in pain, discomfort and stress.
2
Of course, the Widow Maker severe Left Main lesion is best treated with Bypass. However for stable angina, outcomes are comparable for medical management, and revascularization with stenting or bypass. For example, Dr Hueb reported in 2004 on his (MASS-II) randomized trial comparing Medical Treatment to CABG, and PCI (percutaneous intervention with balloon and stenting). 611 patients with stable angina and angiographically documented double or triple vessel disease were randomly assigned to one of the three treatments, 1) medical treatment, 2) CABG or 3) PCI. Here is a quote from the authors:“Our results are consistent with the Coronary Artery Surgery Study (CASS) trial, in which no difference was seen between patients in the surgical and medical groups in terms of mortality, Q-wave MI, or event-free survival rates after five years of follow-up."endquote. (Hueb J Amer Coll Card 2004. ) One might say that in some cases, medical management would be a better choice. For more on this topic see:http://jeffreydachmd.com/2013/09/39-reasons-avoid-bypass-stenting/
12
But the CASS trial as well as the VA and European trial (which were all performed around the same time) all showed survival benefit for bypass surgery at 10 years followup. You left that out.
1
Mr. Carroll seems so anxious to drive home the point that many stents are unnecessary that he badly underplays the situations in which cardiac stents may be lifesaving--someone in the ER in myocardial infarction--or may help a patient avoid far more invasive open bypass surgery for one or more totally blocked coronary arteries. The problem is that people will read this article or particularly just the first two-thirds of it and come away with the message that stents are worthless, unnecessary therapy designed to inflate MD and hospital income. If they or their loved ones refuse consent to a lifesaving procedure in a true medical emergency thinking they're being scammed, Mr. Carroll has not helped. Please continue to expose unnecessary medical care, but please do it more responsibly.
47
Article is titled, "Heart Stents Are Useless for Most Stable Patients. They’re Still Widely Used. " Stable is in the key, this commentary has nothing to do with people with unstable angina or acute MI.
9
Exactly right. Well said.
2
This seems to be just one more article subtly pushing the agenda that Americans over 55 or so are a waste of medical resources and should just be shoved off a cliff. Hello, NYT, it may be difficult for you to believe, but seniors ARE human beings and many have families and spouses who love and value them, and want them to stay alive.
5
Always get a second or third opinion - particularly for such an ambiguously valuable procedure.
3
Easy to do in the ER at 4am, when you are blue, unable to breathe, and the proverbial elephant is sitting on your chest. Then, when you get 3 opinions, which do you pick? The one who recommends a serious change in your diet?
1
No data evidencing use of ECGs first: to document patients’ cardiac blood flow before and after non-invasive medical therapies, before considering/introducing stent placement as option? Why not?
7
ECGs show NOTHING about blood flow; only about the electrical activity of the heart. Angiograms use dye to determine blood flow, and are always done before and after balloon angioplasty and stents. But the studies show that there is more to angina than improved blood flow.
2
It is makes Big Pharma a profit, it will be used...even if it kills or bankrupts the people who use them. Big Pharma's slogan should be, "Making American Great Again."
4
You have to take into account secondary effects.
1
Coronary angioplasty and stents have a role to play in acute myocardial infarction, but not in stable coronary thrombosis but stents make hospitals and cardiologists a lot of money this explains their appeal. Interventional cardiologists now prance around hospitals the way cardiac surgeons once did. Content in the knowledge that they are the intitution's best revenue stream. Now that the NY Times has let the cat out of the bag to the public (doctors have known for years), hopefully payors will deflate their balloon.
Next are ventricular assist devices...
5
Whoa... that's some rant. The Interventional Cardiologists at my hospital have put the brakes on their use of procedures for chronic stable angina as a result of this paper.
Ventricular Assist devices pump blood to the body in patients who's hearts have nearly completely failed. In fact, many patients now opt for them over a transplant. Multiple well done studies have proven their efficacy. Cost and complications certainly need to be considered, but don't just start randomly attacking all procedures.
I suffered a heart attack which came as a big surprize to me. I had just biked my usual 30 miles. A stent was placed, saving my life. Another was placed 6 months later. I am now further inspired to eat right, exercise and enjoy my life. If another attack occurs I’ll be ready. Until then I have a new lease on life. These studies seem to play into the insurance companies hands to limit the payouts. Same situation with regard to the PSA test.
21
Good point re insurance.
2
Each and every time I have had surgery or fixes there are more problems as a result. Do NOT go under the knife unless you absolutely have to. For any reason. Doctors are all too happy to cut you open. I've turned down numerous opportunities and healed naturally. Question those who are all scalpel happy. And seek a second, even third opinion. You also risk serious even fatal infection.
Don't jump on the prescription bandwagon either. Ever hear about those side effects? Worse than what ails you.
7
I worked with lots of stented patients before retiring as a nurse. Prior to stenting, most patients who are stable undergo at least one set of stress test/cardiac imaging prior to the angiogram/angioplasty. Together they highlight poor perfusion/blood flow, in addition to EKG changes and subjective feelings of chest tightness, shortness of breath, etc. Before the time rigorous medical treatment and diet/exercise changes can work, the patient could suffer an adverse heart attack. BTW, dietary changes and exercise are always necessary, as are appropriate medications. There certainly are folks who fit into the gray area of either/or, and yes some stents do create problems (such as near a corner where the artery turns), but many stented people successfully avoid open heart surgery, which creates its own set of problems, and potential heart attacks, which set folks up for heart failure.
14
I'm finally glad to have gotten the opinion of a pediatrician regarding the stent I have in my left anterior descending artery. I never felt any pain and did not have two stents inserted to reduce pain. There were slight twinges in my neck at random times--sitting, maybe exercising---nothing I could not deal with. However, a stress test and angiogram showed significant blockage in my LAD. The physicians at the large Boston cardiology department told me not to leave the hospital. I did, anyway, and came back two weeks later for the procedure, which I did without sedation. Now, I can't tell you I feel better, because I never felt bad in the first place. But I do know the offhand way in which you dealt with the issue here--by referring to this with stable angina--instead of explaining what that means, does a disservice to readers and may prevent some people from getting stents who were not the subject to this study.
The study said nothing about those with unstable angina. To readers the difference will by cryptic. Why don't you explain it instead of seemingly impugn all stent placements by not adequately describing the narrowness of the study.
34
Clear response. Thanks.
I'm a physician who has a stent and am still trying to get my head around this latest study. I developed stable angina without a heart attack in 2013. My diagonal artery, a small one, was partially blocked. I received a stent and I was put on atenolol, a B-blocker, and cornerstone of medical therapy. In the ensuing 4 years, I have had no symptoms with vigorous exercise, including hiking at 12000 feet in Colorado. Can the medical therapy be that good if the stent was ineffective? Is the stent helping or even still open? I'm pretty sure there is no placebo effect as the anginal pain was severe with a little dancing at sea level and absent hiking uphill at high altitude. These remain unanswered questions in my particular case.
3
Of course it could be. It is called collateral flow. We always underestimate out bodies ability to heal.
2
I’ve thought about collaterals, but the hike was probably before they had time to develop. Since then, I’ve hiked every summer at 8-10000 feet without difficulty. And, of course, with better diet and larger statin dose, there could be regression of other lesions, but without another angio (not indicated), that’s not knowable either.
Heart attacks aren't the only measurement of a stent's success. Neither is lack of pain. How about more energy? I couldn't take beta blockers to alleviate the effects of a semi-blocked artery. (They often intensify even minor asthma.) Stents were inserted, and I felt the difference immediately. My doctors saw the effect too, if their "wow"s in the procedure room were any indication. They could see the blood now flowing freely to my heart. "The New Health Care?" Not for my body this time.
2
The article is honestly written but it is also worthwhile doing a careful read of the original paper in NEJM.
The group of coronary artery disease patients who are included in that study is VERY limited.
1. Canadian angina classes 1,2, & 3 included = no patients have symptoms occur at rest or markedly limit activity.
2. So, patients having 'heart attacks' not included.
3. Can only have 1 of 3 vessels with significant blockage (70% or more).
4. 92% of patients have normal heart function (normal left ventricular ejection fraction). This is a good prognostic sign.
5. Prior to procedure (angiogram), 6 weeks of careful addition and adjustment of heart medications with at least weekly cardiologist contacts.
6. Excluded: prior bypass surgery, blockages (stenoses) in left main artery, unstable angina.
The vast majority of reader comments are describing personal coronary syndromes that would not be included in this study. Therefore, study results do not apply. (read label before using)
9
It is worth noting that the COURAGE trial quoted first in this article was conducted by the Veterans Affairs Cooperative Studies Program. VA has been a leader in conducting trials that others have no incentive to conduct. Implementing the findings from this trial throughout US healthcare would save the US billions of dollars, and implementing the results of other VA comparative effectiveness trials would raise this to tens of billions.
2
Is placing a stent always black or white whether it is a necessary procedure? Assuming there is a gray area with some patients, can't you make a reasonable case that the strong placebo effect in such situations actually confers a quality of life advantage to the patient (feeling better)? On the flip side, if stenting was necessary but with 20-20 hindsight should have been performed, how is that outcome rationalized?
If that is true, a sugar pill with a promise that it has the same effectiveness as a stent would be cheaper.
Hooey - The psychological impact to the patient by placing a stent is probably a lot greater than from swallowing a sugar pill.
The article and cited studies are about stents being placed in stable patients; not those who present with myocardial infarctions or unstable angina for which stents may be very appropriate. The issue is that for patients who are stable are stents appropriate? Studies seem to show otherwise and that optimal medical management is just as effective. Consider that a stent is at least 10k a pop and medication is still needed after the procedure. Wonder why our health care costs are so high? Follow the money
14
i remember in my 3rd year of medical school watching 2 of my classmates argue at full throttle over some piece of minutiae they thought they knew about a disease they hadn't even heard of 24 hours previously. I bring this up because i have found in my 30 + year history of being a physician, that once a physician thinks he knows something it takes an awful lot of of disproving science, before he will accept that what he thought wasn't right. I guess that is human nature, and that in some future cardiologists will be getting trained by people who accept the facts on stents. As for patients, when talking about disease with potential fatal results, they almost always will vote on doing something ( even if there is no chance it helps) than on small changes that might modulate the prognosis. human psychology is a fascinating thing, and it would empower us (physicans) to understand ourselves and our patients better.
24
Thank you for an interesting post. Your last sentence applies to other areas such as management.
1
Here is an interesting situation. I had stents that were poorly installed and have caused me nothing but grief. They have since healed into my heart structure and slashed my quality of life. I believe I did need them, still do...but there are good mechanics and bad mechanics. Same with cars. When a defective car meets a crummy mechanic the mechanic just blames the car.
11
HMM A patient undergoes a procedure and a blocked artery is seen. Does the patient opt to be placed on medicines and if the medicines do no relieve the pain undergo a SECOND procedure to place the stent or do they opt for the stent at the time of the initial procedure and still go on meds. I can assure you that there are not many patients that will opt for not having the stent at the time of the initial procedure.
5
I am currently seeing a cardiologist because of occasional chest pain and tightness that started happening about 3 years ago, but has become more frequent over time.
My BP and cholesterol are both very good for someone my age (51). I'm an avid cyclist, logging thousands of miles a year my whole adult life. So far there has been no explanation for my symptoms after a chest X-ray and an ultrasound. I'll also be undergoing a sleep study to check for sleep apnea, and a CT angiogram once my insurance agrees to cover it.
This article seems to miss the target that a few of the comments hit. That as far as stents, it's important that *all* the coronary arteries are checked for blockages. If someone has a 75% blockage in the main artery and 40% blockages in 2 or 3 other arteries, then of course only placing one stent to relieve the worst blockage won't totally eliminate the problem.
6
My father, who ran and worked out all his life, had a heart attack at 72 - he was found to have three out of the four major arteries completely blocked, and had stents put in. It turned out he had hereditary heart disease, and his doctors told us if he hadn't been so fit he'd have had the heart attack twenty years earlier instead of surviving with no heart damage. Medical therapy was not an option, because he had no symptoms of heart disease and aced his yearly physicals for decades.
As I understand it, stents have taken the place of most open-heart surgery procedures. Maybe they aren't a solution for all heart issues, but I doubt my father would have recovered as well from an open-heart procedure.
3
Stents are not placed in arteries that are only 40% blocked. Typically it is a minimum of 70%, though a procedure called FFR is becoming more widely used and provides better information on which arteries to stent.
1
I got my first stent in 2003 (I had another 10 years later). Back in those days, the patient was conscious throughout. The instant the stent was opened in m artery, it was about 30% easier for me to breathe.
7
Life style changes are critical for any secondary prevention.I had a stent in 2005 for single vessel.In 2013 I had CABG of LIMA for the same vessel.I maintain a BMI of 23.I am now 78 years.My EF is always above 60%.
1
This is an incredibly misleading headline and article. Stents saved my life. Five years ago I suddenly couldn't walk two blocks without gasping for air. A stress test showed two significantly blocked arteries. Two stents were put in, and I soon felt better. Now can walk for miles, swim vigorously each day and am in better shape than I was 20 years ago. Without those stents I probably wouldn't be here to write this comment.
Why no mention of the hundreds of thousands of people like me?
www.newyorkgritty.net
47
Agree, lately NY times specializes in incredibly misleading headlines, especially, when they can justify cutting healthcare or any other quality of life initiative.
4
I am one of those survivors too. My new god is the stent. Clearly this pediatrician has never had a need for stents. Look forward to his “after stents saved my life” article!
3
I interpret the story that the NYT is just trying to present a balanced picture of medical interventions....that everything needs scrutiny. Just because an intervention exists it does not mean automstically that it is beneficial. Just look at the mess around opiods occurring in North America, from overprescribing to cutting people off cold and forcing them on to the street for severe pain.
1
The article fails to mention that when a coronary artery is completely blocked an acute heart attack occurs which calls for a stent to be installed asap. It happened to me.
25
How many stents (and what proportion of the total) are placed in patients who show up at the hospital or ER with an artery that is 100 percent blocked or nearly so? This is basic information, but is not provided in the article. Likewise, what about the utility of stents in patients with unstable angina.
It is not difficult to believe that stents may be overused, but a news article (or even an effective advocacy piece) should provide some context.
33
The hearts called a “vital”organ for good reason. Many other diseases are the result of disease in the cardiovascular system as well. I don’t believe cardiologists are coming to their offices gleefully looking for their next patient to line their pockets. The problem IMHO, is with the difficulty, ethics and expense of doing better studies, of the pressure to offer patients the standard of care (in this case stents) or face a lawsuit and the slow, cautious pace that medicine takes before they change how they “intervene”.
Trying to relieve pain and increase quality of life isn’t a bad thing and $10,000 is pennies compared to long term nursing care from debilitating pain, stroke or worse.
Cardiologist have one of medicines most challenging roles and I for one think the majority are dong their best to keep aging, diseased, fat laden, inflamed hearts and vessels from killing the people they care for. They certainly don’t want to do risky procedures on someone they are trying to keep alive unless they felt medical studies supported them.
5
This article is flawed because the cardiologist did not do complete heart angiogram.
The limiting factor for stable angina is the narrowest vital artery and if the doctor did not look into this and keep trying to fix the previously occluded grafted arteries, then it would appear stent is useless. This is not true because the one hidden away is the real culprit.
Demand a complete heart angiogram, not just the usual culprit like those grafted vein used after a bypass which usually fail after ten years and need constant restenting. The problem as I said is the other arteries, specifically the left main artery, left circumflex artery blocked by calcium deposits in many cases. Demand this angiogram while the doctor do stenting on the known occluded vessel. That should be the focus of future stenting, usually after rotoblation to overcome the hard calcium deposits.
5
They do stents without doing a complete angiogram? I had a 99% blockage on the top of the left descending coronary artery, with no pain. I felt discomfort, mild aching with exercise in my left arm and going up my neck. I had an abnormal stress test; but after the several months it took to get into the cardiologist for the angiogram, my symptoms were much improved and I was back to swimming laps for an hour and mild hiking. I did have to stop and bring my heart rate down regularly. The 99% was a big surprise for everyone.
It was stented. Would this fall under the category of warranted stent?
4
The problem is the interventionist went for the usual suspects, those grafted veins. Then they occluded every few months, even over a year at best, repeating the same spot, never to look beyond at other arteries.
Now why would they? I can only suspect, it is less risky to do multiple stenting and also good $ repeat business UNTIL I found out in an ER situation it was That LMA and LCX that was the culprit. Way back it was the LAD that started the need for CBAG.
So to cut long story short, the bypassed grafted veins are now totally irrelevant and I am monitoring the new stents at LMA and LCX.
Remember the Limiting Factor is the most occluded one that contribute most to angina and heart attack, and in this case the bigger pipe LMA probably is the biggest factor, not the grafted vein, so doctor was Looking At The Wrong Places.
After triple bypass surgery 17 years ago and one subsequent stent 10 years later for a failed venous graft, he continued to have initial chest pain upon starting walking exercise. This pain finally disappeared after a second stent was inserted a few years later, in a difficult to diagnose arterial area behind the heart, uncovered by a cardiac physiatrist’s sleuthing work.
2
I will require more research than is indicated here to accept the proposition being put forward - I currently live in the UK where the NHS is under terrible strain. I have witnessed firsthand the level of care provided to seniors in the NHS versus seniors getting medicare in the US and the latter receive far better care than they do under the NHS. I am not saying that there is a policy of rationing of care for seniors in the UK but there is I believe an unconscious bias in that direction. Hence I would be rather more skeptical of the British study within the current environment and certainly over the last 15 years or so.
7
NHS is not an unbiased body, as you state they have extreme motivations for cutting care and procedures to elderly.
3
Not a cardiologist, but a hospitalist.
While profit does play a role in this, there's also a defensive aspect as well. People with coronary artery disease often do have heart attacks, and some die of these. If I were to evaluate a patient, find that they had stable angina due to single vessel disease, advise NOT to place a stent, and then have them suffer a large heart attack two months later that is ostensibly unrelated (let's say it's a different vessel altogether), I'd be very afraid I'd lose that malpractice suit that would come my way.
It would be easy to argue that the standard of care (what most doctors would do in that situation) wasn't followed, and my advice not to place a stent was malpractice.
On the flip side, I'd be far less likely to be exposed to a malpractice action by recommending a stent, even if there were a complication.
It is important to note that stents in and of themselves do not prevent heart attacks. They fix a point problem in a system of vessels that have innumerable other blockages that can progress quickly from a 30% closure to a 100% closure. The medications are the key to preventing that progression, not stents.
If your sink stops flowing due to hard water, and you don't do anything about the hard water, your shower and toilet will stop. You'll make your plumber happy if you call them each time, but the real solution is to address the underlying problem - the hard water. In CAD, it is the medications that address that problem.
15
Working in Cardiac Surgery there have been many studies done over the years showing that open heart surgery (Coronary Artery Bypass grafting) is much more effective than stents for patients with blocked arteries. Now I guess we know why - an actual corrective procedure versus a placebo effect is the reason.
2
10 years ago I couldn't breathe after the slightest exertion such as walking up the street. An angiogram show blockage over 90% in several major arteries. Four stents changed my life. I could breathe again and exercise. Stents saved my life. Several generations ago, my aunt who died in her fifties, had to limit her exertions because of a "weak heart. ". Who knowsif stents would have helped.
There are 2 sides to every story. There are many useless procedures in the medical field. To be totally convinced of the value of stent procedures on the basis of a few tests is irresponsible.
14
The question is not whether PCI should be done at all rather in whom should it be done. In your case it seems that with 90% blockage the stents did open the arteries. But should it be the first course of action if someone has only 25 - 45% blockage?
5
No indication for stents in patients with minimal disease.
Physicians tend to recommend procedures. In extreme cases, action is warranted. But I like the motto, "Don't just do something, stand there."
I went into the local emergency room about 8 years ago with chest pains and elevated blood pressure. It turns out, I was having a muscle cramp in my back that extended around to my pectoral muscle on the left side, plus a little bit of panic.
Even though I tested negative 6 times over the next two days for the enzyme that shows damage to the heart muscle and passed a stress test with flying colors, a cardiologist still wanted to perform a catheterization. He didn't give me the results of the enzyme test, but the cardiac nurse did.
In short, my insurance paid about $10,000 (and I paid about $2000) for a completely useless hospitalization. They should have sent me home from the ER after some observation. Physicians, and surgeons particularly, perform a lot of needless procedures. No wonder our health-care costs are out of control.
14
to varying degrees my reply to headline is same as majority of other comments I read:
Stents are used because insurance companies fairly universally approve the procedure & people seldom die as a direct consequence of the procedure.
This is not the sole criteria (insurance approval intersecting with no immediate death) for modern medicine but for far too many people in need of clinical intervention it is all me see.
5
It's all about money. Since the seventies when doctors, hospitals, drug companies, and the device makers learned that Medicare, Medicaid, and insurance companies will pay the bills and patients (not having to pay from their pockets) will expect more and more tests, treatments and surgeries the dam of dollars have opened to fill everyone's pockets.
Almost 20% of GDP goes into the healthcare industry. It's much bigger than military industrial complex. Both waste much of the money spent.
9
Angina with moderate exertion getting worse followed by catheter procedure revealed 95% blockage of LAD, stent placed 3weeks Ago. Some initial phantom pain, apparently normal, now feeling much better, no angina and better energy, and much less stress about potential imminent heart attack. Bottom line, this was right procedure for me, probably a life saver, and I am thankful for it.
8
The stent will not prevent a heart attack, but the medications will. The medications are the key to reduction in risk of a future event. The stent fixes one small problem area in one artery - but the smaller blockages that were not amenable to stenting can cause heart attacks, which is why you need medications.
6
Exactly, to which medications are you referring? I take an aspirin nightly, and have for 50years. I also take Altace twice per day. Both parents died from major heart disease. Dad @42 (sudden cardiac arrest) and Mom@ (82) with 99% blocked main artery & aortic valve replacement. Thank you, NB!
Why? I am not a doctor. I don't have one of these and by George, I'm going to try to avoid needing one.
Don't ask just me.
There is a whole medical machine angling for certain things to happen and I can't fight that off in my own.
1
Yet another article from the NYT about the efficacy of cardiac stents. This paper has been printing these regularly since 2006, but the use of stents is still growing. It's time to name and shame the doctors and hospitals that continue to perform this procedure for profit. The AMA, AHA, FDA, and Medicare are all culpable here too. Go find out who is pushing for stents, and which of the hospitals and medical device companies are interfering in the regulatory process to keep the cash cow going.
7
"Why are so many people paying so much — and putting themselves at risk — for a placebo effect?"
Umm, because our medical care system in the USA is for-profit?
6
More like because the recipients aren't paying for it.
If the $10k charge hit your wallet, there would be outcry. But Medicare covers most of these.
20% of $10k is still a lot of money for most people! Medicare is not FREE!
The Placebo effect last for up to 90 days which well exceeds the six weeks that they tested the patients. how can you make a determination as to whether outcomes are from a placebo effect when you don't study them long enough to remove that correlation ?
8
This is another example of overdiagnosis/overtreatment that add 20-25% of health costs. Most patients want everything possible done because health is priceless, but do not want to waste money on poor people. There are many more medical myths that work in theory but in objective studies are not true.
3
Having had quintuple bypass surgery 17 years ago & 7 stents since, I find this article very interesting. I have stable angina that is often triggered by walking especially after eating (recently I'm having angina at rest, which is worrying). I religiously take all my medications. What I find disappointing about the article is that it doesn't report how patients who don't get stents treat their angina. I treat mine with nitroglycerine pills. Usually 1 does the trick, but lately it may take 2-3 to relieve my pain. So, at what point does a person need to get medical intervention for angina or do I just pop a nitro as often as I feel necessary?
9
Mike, I had a stent 20 years ago in a 95 percent blocked artery; 3 others were partially blocked at 70, 40, and 30 percent. Never could tolerate statins because of insomnia (tried several through Johns Hopkins) or other meds. So I've followed the Esselstyn very low fat diet (online) and in a book) for years. Hard to adhere but no cardiac problems for decades. Everyone in my family going back 3 generations has died from CVD, some as early as mid forties (my stent happened at 56). My cholesterol went from 245 to 149, LDL from 160 to 80. Published studies are online. Hard to do but what's your choice?
2
Let me add to my comments: Two online studies show drastic protection against heart "events" following the Esselstyn diet, one over 99 percent effective versus reported 30 percent effectiveness for the Med diet. No exercise or meditation etc. required although I walk up to 5 miles a day because I feel better doing it. I take an 81 mg aspirin daily and had done so years before the stent. Before I got my stent because of quickly worsening angina I had been a lacto-vegetarian for years (eating olive oil, nuts, etc.) and walked miles in the course of a day.
Are there any studies of the effectivity of stents in cases of hearts with blockages? In July 2006, two stents were placed in my heart to open significant blockages that were found by catheterization. I had no symptoms, i.e. no angina, no shortness of breath, etc. In May and June 2006, I completed bicycle rides of 100 miles each, including more than 10,000 feet of climbing. I was 62 at the time. Perhaps I'd have done as well without the stents, but grateful to have them and the 12 years since!
7
Like my story; Grateful Alive (LOL)
1
Yes there are a lot of unnecessary procedures being done by many physicians, but there are some glaring omissions in this articles. This study was about unstable Angina; the benefits of stents are more in allowing for the blood flow in MI (heart attack) cases to the damaged or blocked artery to the heart muscles though. And it works.
10
Interventional cardiologists love to intervene. It's what they're trained to do.
But, really, the US health care system is built on some basic beliefs: It's better to do something than it is to do nothing. Expensive, high tech care is better than less expensive, low tech care.
Both beliefs raise costs a lot, even though both are wrong. Sometimes doing nothing is better. Low tech, less expensive care is often as good or better than shiny new technology.
Until we learn these things, we're overpaying for health care.
4
First let me say that medicine is a business, and any threat to the doctor's or hospital's cash flow is seen as a threat. Medicine in this country is not focused on making people well, but more on treating symptoms with the most costly therapy available. This benefits the industry but not the patient.
As I asked my doctor once, do you get a bonus for making people well? He did not answer.
How about some focus on addressing the cause of the need for stents or drug therapies? Or looking at cases where people have chosen alternative therapies such as revising one's diet and and integrating regular exercise in improving cardiovascular function?
Articles like this are like arguing what type of fiberglass body filler is best after an accident, rather than addressing the cause of bad driving.
6
I'd like to see this randomized study include other therapies beyond medication, i.e. include Dr. Esselstyn's plant-based diet heart disease prevention and reversal program. That therapy requires no pharma or medical intervention and therefore has no profit motive.
6
More options are open -- and whether or not the one I chose is due to the placebo effect -- who cares!I works.
Over two years ago I had angina -- so painful that I considered going to the emergency room at night I could not walk one block without distress.Had to stop stress test almost at the start( did no invasive tests...)
Then I discovered the protocol based on Linus Pauling studies -- I started with vitamin C ( I take 6 gm. daily).Eventually I added l-lysine, (1000 mg daily) and l-proline (500 mg daily). I take the C faithfully, and often skip the last two .
I have not had a single angina attack, and recently marched (protest :>))) for one hour non-stop -- in cold weather. Not a twinge.
Medicines do their magic invisibly and often subtly, and should thus make us more open to the placebo effect. I suspect that stents have had staying power with physicians and patients simply because the mechanical principals behind them seem so obvious: the vessel is closing up, and a rigid tube keeps it open. Even a child can grasp the mechanics involved.
The interesting question here is, if something as intuitively obvious as stents don't work--then why not?
6
Why not? Because the problem isn't mechanical, it's physiological or biochemical? Which diet and exercise and, if necessary, meds can address?
4
I read an article back in the 1980's that stated that in the ER when chest pain, possible heart attack patients arrived they were split into two groups. One group of patients received antibiotics the other group of patients received the normal cardiac procedures. The outcome for the anitbiotics patients was far superior to the normal cardiac procedures at that time.
The cost of the antiobotics was a lot less than the normal cardiac procedures.
1
This article does not adequately differentiate between the effects of stents in patients with unstable angina/stable coronary disease and those with myocardial infarctions. This is a very important distinction: patients who are having a myocardial infarction (i.e. a heart attack) have a severe enough blockage to cause damage and necrosis of heart tissue. If this blockage and subsequent damage goes unchecked, it can be life-threatening. In these patients, stents (or coronary artery bypass surgery, depending on factors specific to each patient) are beneficial – it opens the artery up, allowing blood and oxygen to flow to the damaged tissue again.
However, this article is not about patients with myocardial infarctions. It’s about patients with unstable angina/stable coronary artery disease - not severe enough to cause damage. Someone who is already familiar with the topic would see that; however, I imagine the average person reading this article would not, through no fault of their own.
Some comments here have pointed to a conspiracy of physicians to place stents in order to increase profits. That’s not the case. Are stents and the procedures to place them overpriced? I don’t know – that’s a different question than looking at the risks and benefits alone. Do physicians place them in order to pad their wallets? No.
Please talk about these things with your physician. There are so many individual factors that influence decisions that are not addressed in articles like these.
30
"Do physicians place them in order to pad their wallets? No."
While I admire your confidence in the good angels of physician behavior, nonetheless, I think there's good evidence that a financial motive can intrude. In fact, there are repeated studies that show that physicians are more likely to perform procedures when they profit from them. The effect may not be overt or conscious, but it's real.
8
More to the point -- carpenters with a hammer look for nails to hammer. Ditto, heart surgeons, looking to cut. Talking about self-fulfilling wishes.
For profit medicine is the culprit. You need universal health care to help eliminate unnecessary procedures. All surgeries have risk.
8
"universal health care" has nothing to do with whether or not medicine is "for profit." the first has to do with how people access the system, the second has to do with how care is priced. the two coexist in many national systems.
2
Universal healthcare will work, when there is a universal tree of money in every home, until then look at NHS for a (non)working example of universal healthcare.
1
Funding is being removed from the NHS and that is devastating. May gov is doing austerity instead of investing.
This applies to STABLE (not actively having a heart attack), SINGLE-ARTERY DISEASE patients who take their pills religiously.
Not all stents are bad. Read carefully.
60
My left descending artery was 100% blocked. A stent was placed and it was opened. i saw the pictures afterward. I am not sure I would have survived without the stent.
17
Next up: All the people who SWEAR their lives were saved by stents and everybody should get one.
6
A short answer to your headline?, our de facto criminal health care system where the patient is put second or last to the billionaire HMO or Drug companies.
Don't get me wrong, modern medicine can work miracles sometimes but the other 80% of the time they can't help you, tell you what you already know or outright rip you off like with this procedure.
2
Stents are useful in placing a second Mercedes in the heart doctor's garage or a Swan yacht at their yacht club or even a vacation home in Vermont, oops they have that one, then a third home at Beaver Creek for investment purposes, which they are allowed to use for vacation for no more than fourteen days a year.
5
Isn't it illegal or at least immoral to run tests of this sort on humans? What if either group had shown massive differences in survival?
1
Under internationally agreed principles, studies on humans may only be approved when there is "equipoise." That means that, going into the study, no one knows whether the control wing or the treatment wing will do better. When this study was approved, it was already known that stents did not improve survival in cases of stable angina. The only issue on the table was whether the stents improved comfort--at the risk of serious complications. Under those conditions, the sham treatment was ethical.
Where lives are at stake, studies usually have conditions under which someone may "unblind" the data. In such cases, if one side or the other is patently superior, the study may be ended early to switch everyone to the superior treatment. This is a rare event.
4
Thank you, Mike.
it is worse than you say- almost all the reduction in mortality attributed to the stents coincides with the use of dual anti platelet therapy. Look at the FEARON study. The medical and stent groups have identical survival after the dual anti platelet therapy is stopped at 18 months. The only proven role for stents is in the case of acute MI with ongoing ischemia. Of course the income of cardiologists is greatly dependent on PCI so their attitude is dont confuse us with facts, we know what we are doing.
7
Are humans good consumers of medical care? No. Frankly, humans, in general, do a lousy job of taking care of themselves and don’t make well advised decisions, even when their medical professionals make recommendations. Humans rely more on commonly-held-beliefs and perceptions of related experience than hard data. If Uncle Harry had a good outcome with a stent, then I want one too. After all, insurance and/or Medicare is a paying the bill and since it worked for Uncle Harry…
Lastly, it usually isn’t the individual telling the medical professional: “I want a stent.” It’s the medical professional saying: “I want you to have a stent.” Is this just making the patient feel better, avoiding malpractice, or adding a billable procedure? I don’t know what motivated the medical professionals. However, unnecessary medicines and procedures have been a part of medicine for a very long time.
6
It’s too bad such a serious topic was handled so simplistically with short shrift given to when stents are life-saving.
My wife—a slim, fit non-smoker—had been experiencing chest and back pains for weeks before we were due to leave the US for Paris. She had sailed through EKGs and a nucelear stress test previously; on a final checkup before we left she was told categorically by her cardiologist “it’s not your heart.” As we walked endlessly through the old city and even climbed the bell tower at Norte Dame, the pain worsened. Believing the symptoms were somehow related to a hard fall she had taken weeks earlier, we tried to schedule a visit to a spinal specialist.
By the time we landed in Philadelphia, the pain was so bad we went straight from baggage claim to the ER. She’d had a heart attack on the plane. Originally, the interventionist believed she had 100 percent blockage of the LAD. When he reviewed the film, he could see a tiny burp of blood getting through. With her new stent, she is exercising daily, working in the garden and taking long hikes with no pain and wide open coronary arteries. Please tell me what other medical intervention could have saved her life.
43
Her situation isn't the one being discussed here. Stents are proven to have benefit for active MIs with ongoing ischemia.
13
What if angus's wife was stented prior to leaving for Paris, and not wait for heart attack? The 3-year residency trained pediatrician here claims superior knowledge over 8 year trained interventional cardiologists.
Thirty years ago I encountered a doctor who displayed a poster in his waiting room that read:
"God heals. The doctor takes the fee."
Grinning, I asked him what the fee was for. Grinning, he replied, "Keeping the patient amused through the process."
Soon thereafter he closed his practice and focused on local nursing homes. I was told staff and patient morale at those facilities improved greatly upon his arrival. A friend who worked at one of those facilities said that doctor told her he was much happier sticking to medical practice and leaving the insurance paperwork to the staff who weren't allergic to it.
7
There is a remarkable scientifically proven method to prevent and most times reverse heart disease even after patient have undergone stents, bypasses or severe cases. Read Cardiologist Dr. Caldwell Esselstyn's "Prevent and reverse heart disease" book where you will learn how an oil free whole food plant based nutrition will do what most current procedures and medications can't. The right foods are curative medicine.
6
Absolutely correct, Diana. Thanks!
I had a triple bypass surgery in 1991 and three stents in 2012 after an emergency visit to the hospital. One graft from 1991 was totally out of commission and after the insertion of the stents, there was no change in my medication. I can attest to the benefits of the stents as my symptoms were relieved.
I may be in a different category of patients, but I wanted to share my experience.
7
Who pays for the sham procedures?
1
Medicare, private insurance, possibly some patient co-pay. Any unreimbursed costs are spread to the rest of us. And of course, we will pay increased Medicare and private insurance premiums. And fewer dollars will be available for more-effective medical interventions.
2
In clinical studies, the entity funding the study pays for both treatment and sham. The study was done in the UK, so the NHS likely had a role.
No one does sham surgery outside of clinical studies, so no one pays for it. No one is proposing sham stent placement outside of clinical studies.
5
Doesn't the article say the research, the sham stents, was done in the UK? Medicare and insurance had nothing to do with it.
stents may well be useful in the setting of worsening chest pain--unstable angina. This is not addressed by studies with stable angina. Be careful about generalizations
11
They made this clear in the article.
5
"They should at least know what they’re paying for." But they aren't; it's paid for by everyone else through insurance or medicare.
7
When you talk about symptom reduction, won't most sedentary people experience pain when you put them on a treadmill, regardless of whether they have a stent? Why be so quick to discount the symptom reduction so many patients report? Did the study measure how much exercise on the treadmill patients were able to do before and after the stent? Exercise "tends to bring out pain" in everyone! I'm 35 and fit, but when I push myself at a race, I feel aching in my lungs and chest that I could describe as pain. Somewhere around 10 pull-ups, my muscles start to burn.
As for not reducing bad outcomes, aren't those also caused by genetics, diet, and lifestyle? If, after your operation, your other vessels continue to fill with plaque and you have a heart attack, does that really mean the stent wasn't effective?
4
They are talking about angina, not the minor discomforts of exercise, which everyone experiences.
1
They're both pain in your chest that occur when you need more oxygen. How did the study differentiate between the two? How did they determine whether it was the "minor discomforts of excercise?"
If bad outcomes are caused by genetics, diet, and lifestyle, why not try changing diet and lifestyle first? Then only those with a genetic condition for whom such changes do not help might benefit from stents -- and they are probably a small minority.
I'm not surprised that a mere six weeks later the stented patients in this study still felt pain. Did they change anything else after a fairly alarming diagnosis? Like diet? I had two stents inserted 27 months ago to open up two completely blocked arteries. Two months later the angina persisted. Then I radically changed my diet to a plant-based whole foods no-oil regimen, as recommended by Ornish, Esselstyn, and others. The angina went away within 10 days, and all my cardiac numbers returned to normal or better. Two years later I see no reason to abandon this highly restrictive way of eating. One gets used to it because the benefits are irresistible. No one treating me at the time of the stent procedure urged me with any force to change my diet other than tossing off the anodyne, "You ought to eat better." There's no mention of diet's influence in this study -- and yet isn't it widely agreed that diet is a major factor in coronary artery disease. Also, the author implies that his caveat about stents applies to "stable patients with single-vessel disease." What about more serious disease that doesn't quite rise to the level of requiring bypass surgery?
19
Good for you! The stents didn't work. Your diet did. It's too bad that a change to a healthier diet isn't the first option recommended. I don't consider a whole foods plant based diet (where whole foods = unprocessed, and plant based = no animal products) to be restrictive. I recently bought an electric pressure cooker (mine is an Instant Pot), and it makes it so much easier to cook whole grains and beans, soups, stews, some veggies, and more. Plus, it's fun! And the food is delicious! I'm now moving to less salt and oil -- I'm a fan of slow but steady change.
7
You're right, going plant-based whole foods (ie, vegan) is easy. No oil is the hard part. Not the restriction or the discipline required, but the vigilance and execution. You have to scout every ingredient label for oil (it's everywhere). You have to adapt recipes and saute vegetables in vegan broth rather than oil. And restaurants are a minefield. I order salads and bring my 3-oz. dropper bottle filled with gourmet-ish balsamic. I'm not complaining. It's a rewarding challenge. Good luck with your next phase.
Only recently I was informed that what had been a stable aortic valve leakage was getting worse, with enlarged left ventricle bringing me close to heart failure, as the head of cardiology of a major hospital said, "either you have an operation to replace the valve or it's a slow but certain death.
He left out two important things. The first is that there are pharmaceuticals, ACE inhibitors, that possibly even reverse the existing LV enlargement; and the open heart surgery in addition to extended recuperation had another consequence, cognitive decline -- severe in the short term and possibly permanent -since I already have very early stage.
Now here's the icing on the cake -- his medical "fellow" with almost decade in the field, responded to my concern about "Post Operative Dementia" - as my personal irrational fear, as she "had never known this to happen."
This disjunction is something I want to address, find the levers of power and then attempt to engage them. I'm trying to connect with the director of a major dementia center, whom I have corresponded with about the adverse effects of informing a patient of his dementia, unless requested. No patient should ever wake up from open heart surgery with memory loss he never anticipated.
Obviously, there are biases at work, but to tread on what a high status doctor considers his/her expertise is fraught, as the danger is losing a personal commitment to an optimum outcome.
10
"Post Operative Dementia". I know it as on-pump syndrome & know it all only too well. Neither my internist nor my cardiologist necessarily agree with me, but neither disputes me or my symptoms.
3
And the answer is: "Stents are also expensive. They can add at least $10,000 to the cost of therapy." If we want doctors to prescribe chest cream as an alternative, just raise the cost of chest cream to $10,000 and that's what they'll prescribe. Not because they doctors are unethical, but because the hospital corporations they are now all affiliated with have an insatiable - and unethical - thirst for profit.
50
Well, gee, who'd they learned that from? "People's presidents" who make $400,000 a speech.
If you have evidence of "chest cream" being charged off @ $10,000 a dose, post it. I seriously doubt you can.
17 years ago I was told at a world famous clinic that I had a heart attack and needed a by pass which I bypassed. 17 years of seeing a traditional chinese practitioner and getting occasional acupuncture and herbal formulas, along with change of diet and qi gong exercise. 17 years of feeling fine, running...with no limitations. Western medicine is not a be all, end all.
20
"change of diet" and "exercise" -- yup!! That's what makes the difference.
3
Bilk now; pay now.
Treat later...or never.
American Healthcare 101: The Greatest Healthcare "Free-Market" Right-wing Rip-Off in the World at 17% of GDP
Half the healthcare for twice the price: Welcome to the U$A ....(....and drop dead !)
16
And this has what, exactly. to do with the "right-wing"? Are Democrats or the left better at deciding what is proper medical treatment or managing the costs thereof? There is certainly no evidence to that effect.
1
The studies just used the wrong metric. Stents have a very real effect -- on the profits of the medical business.
36
I found the lead in to this opinion piece to be misleading, irresponsible and dangerous. It was only after having read half way through that the author admits that his opinion is in regards to those with stable angina. Patients that experience heart attacks due to atherosclerosis can and do benefit from stints. This should have been made clear from the very beginning in order to avoid this confusion.
80
Thank you for noting this. I was wondering about exactly the point you make and which the article doesn’t....
7
"Heart attacks" or acute coronary syndromes (including unstable angina) are, by definition, not stable angina. Thus, they are not what this article is talking about.
This is an relevant medical definition not clearly explained here. He is not taking at all about emergent reperfusion for acute MI, but elective catheterization for chronic chest pain.
14
Recall the cardiac cases of David Letterman, Bill Clinton, and Tim Russert (RIP). DL and BC (both cigar smokers) said they'd been feeling faint, but kept going. TR had not had a recent exam and was, by his own words, in poor physical shape. All had access to Tier 1 medical care.
Your body sends you messages. Listen, carefully.
Physicians make money performing stent procedures, so no surprises there. Most medical practices might encourage their doctors to incline towards procedure when there is room for discretion, which it often is. Medicine is corrupt.
4
As a person with stents who suffered pain on low level exercise before and no pain after, the next day, I don't believe you. Your study results are ridiculous.
8
No, your relief is a placebo effect.
2
Because all medical protocol should be based on individual patient anecdotes...
3
As several others have related, stents certainly work for those who have major blockages, and who are at risk for re-occurrence. Stents may be over-prescribed, but they do seem to save lives (two of my family members, as it happens). Unfortunately, the article glosses over the serious cases in which stents can make a big difference.
25
I had one coronary artery that was 95% blocked. 95%! The x-ray/dye picture looked like the artery was hanging by a thread. I had serious chest pain, and the typical feeling "of imminent doom", which is why I had checked myself into the emergency room.
After a dozen tests, electrocardiograms, MRI's, etc., cardiologist's placed a stent.
This is not a placebo effect, and I can personally attest to it. I wish I could copy and paste the before/after x-ray photos of that artery.
I did not "imagine" this severe chest pain that suddenly came out of nowhere, but only after even moderate exertion. After the stent was placed, I could run up stairs, do heavy labor, whatever, with no pain or fatigue.
By the way, I'm not a bacon-cheeseburger-eating, couch potato kind of guy, and I've been physically active all of my life. Two of my cardiologists suspect that blockages of the sort that I had are caused by genes or severe stress, or both. (I had worked a severely stressful job for 7 years two years before the blockage was detected.)
27
This is a constant annoyance to me. As an internist, I spend hours every week, for no added compensation, trying to get relatively cheap diagnostic procedures and medications for my patients paid for by the insurance companies, only to be turned down half the time. But they seem to approve every stent. Ka-ching.
128
"They should at least know what they’re paying for."
This useless observation ends the story but fails to notice that virtually all cardiac surgery is covered by insurance . The patient may have paid for it, but that was a remote transaction long ago or in the (one hopes) near and survived future. At the moment of critical decision-making all these "rational" considerations fade to the cardiac doctors' choice. Knowing of the placebo research is academically wonderful but coronary arterial blockage is analogized as Russian roulette - and we see ourselves not as a wave of statistics but as an independent trial of one.
9
It's amazing but true: much of medical practice is not evidence based, but eminence based. The field is just now getting around to objectively evaluating previously unquestioned standard operating procedures. The results suggest we are not as far from the days of bloodletting and leeches as we'd like to believe.
13
Objective studies are difficult and expensive to conduct, even more difficult to interpret. But I think the biggest problem is we don't know enough about genetics, a randomized trial might say a procedure doesn't work but you may be one of the 10% it does work for, and the results for your are obscured by you being a minority. This is not to minimize the value of objective studies but just to point out there is also a role for clinical judgment, a physician should be guided by the results of clinical studies but not 100% bound by them.
4
Very interesting. The article ends with the thought that where appropriate patients should be informed of the lack of effect of stents. Fine. If those patients opt for an procedure that is useless for them, who should pay for that treatment. If they pay the entire cost, that too is fine. If the cost is is born my insurance, possibly okay. If the cost, however, is born by Medicare or Medicaid, I've got to think whether that is appropriate.
5
if it's paid for by insurance that means others pay for it as well
8
This will be a difficult sell for patients who know stents exist. The placebo-controlled trial included patients with at least 70% coronary artery blockage and an average of 84%. In a world where stents exist, would you feel comfortable with a 90% blockage in your left descending? We have realized not to ask for antibiotics when we likely have a viral illness. Can we be trained not to ask for a stent since it is not statistically better than placebo? I'll ask again when you are at 90% stenosis.
11
People do demand antibiotics for viral illness. A study in Britain showed that 54% of people are prescribed antibiotics for the common cold.
9
You are completely misunderstanding. Yes, patients want stents, because they are scared and some people, including commenters here, say stents help. Even if all cardiologists would give good advice not polluted by financial interest, patients would still want stents. Does that mean they should get them? Should patients who want antibiotics get them, even if others with beter information know they won't do any good?
8
Stents are emblematic of much that is wrong with American medicine. Prospective double-blind studies fail to demonstrate a beneficial effect. So what? Stent manufacturers, cardiologists and hospitals stand to make large profits from continuing to provide the procedure. The people, groups, businesses and institutions who profit the most can afford lobbyists to keep the money machine working at full speed to support continuing large profits for docs, pharmaceutical companies, hospitals, outpatient clinics and others with a profit-motive regardless of outcome or efficacy of their medications, instruments or procedures. It's hard to see an end to this cycle of profiteering from procedures and medications of unproven benefit or proven lack of benefit.
75
" .. It's hard to see an end to this .."
The person who cares the most about you .. is you. It is you, who has to ask "hard questions." Because it will be you, on the operating room table, in pain and at risk. Worthless memes will not protect you .. only you can.
Prior to having two stents placed in my arteries, I could not breathe. I did have pain in my neck and throat, they said I had GERD, I told my doc tha my dad died at 47 from cad, they did a cath I was 98% blocked, in went the stents. This was not a placebo effect, it really saved my life.
70
Same result here. Stents saved my life, and allowed me to function without angina. 92% blockage.
14
This is eye opening, but left me with more questions than answers. Such as, what are the medical treatments that study says are as good or better than stent placement? If stents still have their place, then what are those situations? If you've got, say, 95% blockage in a major artery, is this a situation for a stent, and if not, how would this be treated to address this blockage? These health articles are informative, and hopefully start a dialogue in the medical community, but more times than not, they don't provide the reader enough information to confidently or responsibly change behavior.
91
Intensive Medical therapy typically include statins, antiplatelets, nitrates, beta blockers. Blood pressure control , excellent blood glucose control if diabetic. Exercise
22
In a functional health care system, your cardiologist would tell you. In the US health care system, s/he just tries to sell you the most expensive treatment.
14
Not diet? More veggies and fruits, whole grains and beans, seeds and nuts? Less to no meat? Stop smoking?
1
It largely depends on the cardiologist; one group we were referred to following heart-bypass continued to treat a family member by inserting multiple stents, and during the last angioplasty procedure, caused an accidental rupture of a major vein. After recovery, I convinced him to leave that group, and luckily found one that rarely used stents, opting for medications adjusted as necessary, relying on stress test results and lab work every six months. So far, so good and it's been several years, but the many stents permanently implanted was clearly a huge mistake and cannot be undone.
17
Current guidelines do not recommend surveillance stress testing every six months or ever in the absence of symptoms. Your current group of cardiologists may also be doing you a disservice with unnecessary testing. I am surprised that your insurance carrier approves this.
3
I am a physician and also the beneficiary of two separate stent procedures in 2012 and 2017. Both procedures followed the dramatic and debilitating onset of both chest discomfort and dramatic exercise deterioration, and stent placement resulted in dramatic and immediate relief of symptoms, for which I am most grateful. These two events were unrelated, the first involving the LAD (left anterior descending coronary artery, also called the "widow-maker"), and the second involving the right coronary artery. On a recent study, both arteries were found to be fully open, and the ejection fraction was normal.
It is possible for the heart to develop collateral circulation in such circumstances, but this takes time, and with it the risks of heart failure, disabling symptoms, and further cardiac "events". In my career I have witnessed the dramatic benefit of coronary stents for many patients, now including myself. I have also witnessed the demise of many patients who were not candidates for stent placement, and the often difficult recoveries of many patients who underwent coronary artery bypass surgery. I am convinced that these stents have not only saved many lives, but have also improved the quality of many lives. According, I would not agree to be "randomized" into such a trial, nor would I advise any friends or patients to do so. That is not to deny the "placebo effect", nor the efficacy of belief and prayer, both of which have demonstrated efficacy.
63
Conviction and belief are not adequate for medical decisions. It appears likely that the clinical studies may not have yet identified a fraction of people who benefit from the stents but are obscured by the average person who does not benefit. I wish an academic cardiologist would add to this discussion.
18
"dramatic and debilitating" onset sounds like ACS not stable angina... no one is arguing your unstable angina didn't deserve PCI.
6
This past spring, I complained to my doctor of difficulty breathing walking up steps. I had just passed a stress test with my cardiologist in February 2017. I went in for tests on my heart and had four stents placed in my heart. if the science is all wrong, if it is, in fact, a plecebo, then why am I breathing so much better? And why can I practically run up steps now? I have greatly improved my diet, cutting out red meat and all fried food, more fruits and vegetables. I am very thankful for the stents. The surgeon said there was a very high likelihood I was a "ticking time bomb" for a stroke or heart attack. So, last year, I listened to my body and rightly reported the pain to my doctor,who referred me to Dr. Fox at Mt. Sinai-Beth Israel, who performed the procedure. These stints saved my life.
23
Benjamin, you asked: why are you breathing so much better and can practically run up the stairs, if the effect of the stents is a placebo? That is your first answer: the placebo effect can be very powerful. You also wrote the second answer: "I have greatly improved my diet, cutting out red meat and all fried food, more fruits and vegetables." That is probably the most important steps you could take to improve cardiovascular health, as well as overall health. Moving to an all or even mostly whole foods plant based diet (where whole foods = unprocessed foods, and plant based = no animal products) has lots of evidence to support it as an optimal diet for health and decreasing the risk of many chronic diseases and codifies. Keep up those good habits!
9
A similar experience. Two years ago, a PA in my PCP recommended a stress test after a brief faint; I also had an occasional micturation syncope episodes and isolated shortness of breadth climbing stairs. Otherwise, all my vitals were normal and I experienced no pain. 6 years previous, over 11 months in 2010-2011, I lost 30 lbs. and 8 in. in my waist thru a wellness program conducted by my PCP involving lifestyle changes in my nutrition, activity and exercise and I’d maintained those changes to the present. I go to the gym 2-3 days a week, Nordic-walk 20 +/- miles a week and my food regimen is mostly plant/poultry/fish-based.
Nine minutes into the stress test, I’m chugging along at a nice incline having fine time when they stopped it because my BP had dropped 20 points. No pain; no discomfort. After consultation with a cardiologist and some additional inconclusive testing (except a gated CT scan that indicated a high calcium score and perhaps some LAD blockage), he laid out my options. Although he did not prescribe a placebo, he did say that, given my excellent health and medical history, choosing to ‘take a pass’ on further procedures was on the table. Instead, we agreed to try an angioplasty; if a stent was indicated, to insert it. It was and it was.
I’ve been back at my normal routine shortly thereafter with no recurrence and much gratitude to a suburb cardiologist (and a PA who had the conviction of her diagnosis). No placebo here.
3
Oh yeah, I'm 76...
There are numerous reasons why stents are being placed for no good reason, but the approach American society has toward medicine is very big. There is an insistence on a "quick fix" in medicine, which is why people demand antibiotics for viral infections in spite their doctor's advice not to take them. Stents in stable angina are like that, except with more complications..potentially lethal. People in this country have got to learn that immortality is not possible and that human disease and the methods to treat disease are not straightforward.
In my practice as a nephrologist, dialysis in the very elderly is an analogous issue. In spite of good studies concluding that medical management at a certain level of kidney function is just good as starting them on dialysis, there is a significant minority of patients (or rather their families) who demand dialysis in spite of the evidence explained to them by me. We have to stop believing that medical procedures will provide an instant cure. This societal defect in this country is a key factor behind what is driving up the cost of care.
93
I would suggest that your profession also reconsider the constant cry of "evidence based" medicine to criticize "other" practitioners who might use therapies that been used for centuries. Acupuncture come to mind as one of these.
4
Ro, IMHO, there is "evidence" that those who repeatedly claim "evidence" really have questionable "evidence."
IMHO, they're really just trying to quickly shut off debate that is needed, honest, frank, and blunt. And they're not really fooling anyone with direct, front-line experience and rigorously-obtained knowledge, IMHO.