From Our 2012 Archives
Stents Overused in Stable Heart Patients
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Study Finds No Benefit of Stents Over Using Medications First
By Salynn Boyles
Reviewed by Louise Chang, MD
Feb. 27, 2012 -- As many as 2 out of 3 elective heart angioplasty procedures performed in the U.S. on patients with stable heart disease may not be needed, a new research review suggests.
The analysis of eight large clinical trials found that the addition of opening narrowed arteries with stents provided no added benefit over aggressive therapy with medication alone as a first treatment for patients with stable disease.
Stents are small mesh tubes that are often inserted during angioplasty to prop open blood vessels and help them stay unblocked. Angioplasty is a nonsurgical procedure that uses a small balloon to open up a blocked artery.
Compared to medication alone, stenting plus medication did not result in fewer deaths, non-fatal heart attacks, or emergency bypass procedures; or improvements in symptoms such as chest pain over four years of follow-up.
Researcher David L. Brown, MD, of Stony Brook University Medical Center in New York, says far too many stent procedures are performed in the United States each year in patients who have not first been offered medication to manage heart attack and stroke risk factors.
"In our analysis a third of patients ended up needing stents because medical management was not effective for relieving symptoms, but two-thirds did not need them," Brown says.
Stents Recommended for Chest Pain Relief
While the benefits of opening newly blocked arteries during a heart attack are clear, several recent, widely reported studies have found little benefit for angioplasty with or without stents outside of an emergency situation.
More than 400,000 non-emergency coronary stenting procedures are performed each year in the U.S., according to the American Heart Association (AHA).
If two-thirds of these operations were avoided, the savings in health care dollars would be huge, Brown says.
By one estimate, reducing elective stent procedures by just one-third would save the U.S. health system $6 billion to $8 billion annually.
The AHA and the American College of Cardiology (ACC) recommend aggressive treatment with medications as the initial therapy for patients with stable angina (heart-related chest pain with exertion) or narrowed arteries with no symptoms.
Yet a recent study found that more than half of patients with these conditions underwent angioplasty and stent procedures before drug treatment.
The new analysis, published in the journal Archives of Internal Medicine, included a total of 7,229 patients with stable heart disease treated between 1997 and 2005.
No Survival Advantage in Stent Patients
Roughly half received stents with medication and the other half received medication alone.
Over an average of 4.3 years of follow-up, there was no evidence of benefit in preventing death, non-fatal heart attacks, heart-related chest pain, or emergency need for bypass surgery seen in people who received stents along with medication compared to people treated with medication alone.
The researchers estimate that up to 76% of patients with stable heart disease could avoid angioplasty and stenting procedures if initially treated with medication, resulting in a savings of about $9,500 per patient.
Practice Is Changing ... Slowly
American Heart Association President Gordon Tomaselli, MD, agrees that too many angioplasty and stenting procedures are being done in a non-emergency situation, but he says the growing evidence in favor of drug management as initial therapy is slowly changing practice.
Tomaselli directs the division of cardiology at Johns Hopkins University School of Medicine.
"As more and more studies show that medicine works well and is cheaper and less risky than these interventions, I think practitioners -- even interventional cardiologists -- will be adopting this strategy more and more," he tells WebMD.
Interventional cardiologist Howard Cohen, MD, of Lenox Hill Hospital in New York City, acknowledges that there is still overuse of stenting, but he says most practitioners in his field are following the AHA/ACC guidelines.
"Most people are trying to do the right thing and are following the appropriate use criteria to make sure these interventions are being given for the right reasons," he says.
SOURCES: Stergiopoulos, K. Archives of Internal Medicine, Feb. 27, 2012.David L. Brown, MD, Division of Cardiovascular Medicine, Stony Brook University Medical Center, Stony Brook, N.Y.Gordon Tomaselli, MD, president, American Heart Association; director, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore.Howard Cohen, MD, director, Division of Cardiac Intervention, Lenox Hill Heart and Vascular Institute, New York.News release, American Heart Association.American Heart Association: "Heart Disease and Stroke Statistics, 2008."Diamond, G.A. Circulation: Cardiovascular Quality and Outcomes, 2009.WebMD Health News: "Many Heart Patients Aren't Taking Needed Drugs."