Two large-scale clinical trials completed within the last seven years have shown that drug therapy works just as well as stents in preventing heart attacks. Former President George Bush, Jr. had a stent placed recently to clear a blocked artery, despite no symptoms. This has put the stent debate back in the news.
The stent debate has been ongoing since 2007, when the Courage trial first found that less costly drug therapy averted heart attacks, hospitalizations and deaths just as well as stents. The results were confirmed two years later in a second large trial. In the Courage trial, all 2,287 patients were given medicine to lower their cholesterol, cut their blood pressure and prevent clots. Half also received stents to treat blockages that cut off at least 70 percent of at least one artery. After five years, there was no difference in deaths, heart attacks, or hospitalizations for chest pain between the two groups.
The debate has centered on both the cost of stenting, which can run as high as $50,000 at some hospitals, and its side effects, which can include excess bleeding, blood clots and, rarely, death. Opponents say the overuse of procedures like stenting for unproven benefit has helped keep U.S. medical care on pace to surpass 3 trillion next year, according to the U.S. Centers for Medicare and Medicaid Services. Each year, more than half-a-million Americans get stents inserted to hold open clogged arteries after angioplasty.
Stents are lifesaving when patients are in the midst of a heart attack but add little medical benefit otherwise. While stents may be used in patients with clear chest pain, there’s no evidence that they prevent future heart attacks.
In Bush’s case, he underwent the procedure without any symptoms after a stress test during his annual physical turned up signs of an electrical abnormality on an EKG. His resting ECG was normal. Interestingly he also had a low calcium score (4) on his heart scan but this was many years ago.
The reality is that there’s no evidence that stenting will help patients live longer, feel better, or have fewer heart attacks.
We can learn a few things from this:
1. Coronary artery disease can be asymptomatic
2. Stents are overused and add to our healthcare cost crisis
3. Stents (and most procedures) are very profitable to doctors whereas prevention is not
4. ECG tests can also be normal even though there is disease.
5. The former president most likely had non calcified plaque when he had his heart scan and has developed the disease later in life.
6. A carotid intima thickness test, done annually would have most likely shown increase intima media thickness and raised flags.
7. He could have had a heart attack any time due a plaque rupture.
8. Heart scans may give a false sense of security since they only detect calcified plaque.