If you think heart artery blockages should be fixed, you’re not alone. For years, cardiologists also thought if we can open a blocked artery with a stent or a balloon, we should.
It makes sense, but in some cases, it’s wrong. Let me explain.
Doug is a 67-year-old man who saw me because he feels like he’s a little slower during vigorous exercise than he should be. He doesn’t have chest pain or shortness of breath, and his endurance is good, but he’s not able to keep up as well as he wants. As part of the investigation of his symptoms, an exercise treadmill test was positive for ischemia, meaning it showed the possibility of blockages in his heart arteries.
An exercise stress test is a useful screening test but isn’t highly accurate. Therefore, a positive stress test usually needs a confirmatory test to look at the arteries themselves. In Doug’s case, I recommended a CT coronary angiogram, which is an x-ray test that directly evaluates the heart arteries to assess for blockages. Doug’s study showed a highly narrowed artery in his heart. Importantly, this artery was a minor one that provided blood to a relatively small area of his heart. When I told him the results, he was initially surprised I didn’t recommend fixing this blockage with a stent.
Who Needs a Heart Artery Stent?
There are almost one million heart artery procedures (called PCI’s or percutaneous interventions) done each year in the US, making them among the most common surgeries performed. However, recent research suggests some of these surgeries may not be necessary.
In broad terms, heart artery stents are performed in two situations. One is during a heart attack or an impending heart attack. This is called acute heart disease. The other is when stress tests or other heart artery tests discover blockages. This is called stable heart disease.
During a heart attack, it is well accepted that opening the heart artery with a stent procedure is beneficial. There is solid research evidence that opening the artery lowers the risk of death, further damage to the heart, and future heart failure.
However, the same is NOT true for most blocked heart arteries discovered by stress-testing when the patient is not having a heart attack.
While it seems logical that opening blocked heart arteries would be helpful, multiple research trials have not shown a benefit to fixing blocked arteries in stable patients.
One of the first large research studies that showed opening blocked heart arteries in stable patients did not save lives was the COURAGE trial. This study compared people who had heart artery blockages treated with stents and medications to those treated with just medications. After following these individuals for almost five years on average, there was no difference in death rates or heart attack rates between the two groups.
The result was a surprise for many cardiologists, and the study was criticized for several potential flaws.
However, a more recent trial showed the same lack of benefit for stents in stable patients.
The ISCHEMIA trial of over 5,000 people with a blockage in a major heart artery were randomized to fixing the blockage and medications or just medications. Just like the COURAGE trial, the study found no differences in death, heart attack, heart failure, or hospitalization between the two groups.
It is now generally accepted that stents in blocked heart arteries in patients who are not having a heart attack do not lower the risk of death or future heart attack. However, the COURAGE and ISCHEMIA trials did show a decrease in chest pain for those who had stents compared to medical treatment alone, but even this benefit is controversial.
The decision to perform a stent in a heart artery involves weighing the risks and benefits. In the case of heart artery stents, the risks of the procedure are known. While infrequent, serious complications such as heart attack, stroke, or even death can occur in less than 1% of cases. Bleeding complications, kidney damage, or an allergic reaction are more common, although still infrequent.
However, if there is no benefit to the procedure, ANY risk is unacceptable.
The decision to perform a stent procedure is a complex one. There are numerous factors to consider, too many to explain in a single article. A thoughtful discussion between the patient and their treating physician that explores the medical risks, benefits, and alternatives, balanced with the patient’s values and goals is necessary to decide the best course
After I reviewed the medical information with Doug, we decided that his symptoms were unlikely due to his heart artery blockage. Since a stent was probably not going to help him feel better, and we knew it would not lower his risk for death or heart attack, we decided on treating his heart artery disease medically. We started an aggressive prevention treatment regimen that included excellent blood pressure and cholesterol control, along with his healthy lifestyle.
One year later, he continues to do well.