Stents are back in the news because of Bill Clinton’s cardiac “event.” Although the former president did not suffer a heart attack, discomfort and pressure in his chest prompted him to seek medical care.
He’d undergone quadruple bypass surgery in 2004, and the doctors who checked him over this time around found that one of those arteries had become completely blocked. That’s why they inserted a stent, a little wire mesh tube that is designed to hold an artery open.
Cardiologists are in agreement that stents can be extremely helpful if someone has severe heart disease like President Clinton. Stents can also preserve heart tissue and save lives if someone is having a heart attack.
What is not so obvious is the value of stents in many other situations. A study published in the New England Journal of Medicine (April 12, 2007) rattled the cardiology community to its core. Cardiologists are still arguing about the results.
The study, called COURAGE (for Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), pitted stents against drug therapy and lifestyle intervention. The 2,287 patients had stable coronary artery disease. That is, they had chest pain, but it was not of sudden onset or particularly worrisome.
Half of these patients were given stents together with drugs and lifestyle modification, while the other half got only the drugs with diet and exercise coaching. After five years, there were no statistical differences between the two groups with regard to deaths, heart attacks or strokes. There was, presumably, a big difference in price since each stent placement costs approximately $15,000.
The results astonished many cardiologists. The drugs used in the study cost far less than a stent and produced comparable benefit, although somewhat more slowly.
Experts expected the use of stents to drop dramatically after the COURAGE findings were published. It did for a while. But stent placement is now back to historic highs–nearly one million annually. If cardiologists followed the COURAGE guidelines, trying medical therapy first for patients with stable chest pain, they would put in one-third fewer stents. This could save an estimated $5 billion each year.
Some critics point out that stents have changed since the COURAGE trial was completed. Even the more modern drug-coated stents come with problems, however. Although they are less likely than bare metal stents to become clogged, they can lead to blood clots and heart attacks unless a patient continues taking an anticlotting drug like Plavix. A month’s prescription can cost over $160.
Plavix (clopidogrel) is not without side effects of its own. Serious bleeding is a constant worry. Digestive upset is fairly common, but the acid suppressing drug Prilosec (omeprazole) may reduce the effectiveness of Plavix. Other side effects may include headaches, skin reactions and blood disorders.
Stents save lives. But if a person is not having a life-threatening cardiac event, it may make sense to discuss medical management with a cardiologist first. COURAGE showed that for many people drug treatment together with diet and exercise can be as effective as a stent at a fraction of the cost.

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  1. nm
    Reply

    I was surprised that the above article on stent use versus medication did not mention that stents are recommended for blockages of 70% or greater. It’s no wonder the article is disturbing to those that have had a stent. Why not publish the recommended guidelines in the article so that people will know there is a standard?
    My cath revealed a 60% blockage of the LAD and the cardiologist said that stents are only recommended for blockage of 70% or more. He placed me on Crestor and baby aspirin. The insurance company will only cover 70% or greater as well. High cholesterol is hereditary in my family and despite diet and exercise still need Crestor. If a repeat Thallium stress test 18 months from now is positive I will do another cath and stent if over 70% blockage. Stents save lives and many people have no symptoms of significant blockage. Many just die unaware of any blockage. Best advice, do your research and hook up with a good cardiologist who is up with the research and best practice.

  2. JRT
    Reply

    I flew in a 3 hour plane trip one way and found my leg to swell. 10 years before that in the same leg I had a blood clot and was hospitalized for one week and then slowly was off the coumadin. Now I have another blood clot and would like to know of a home remedy that would help reduce the clot besides trying to use the Ornish Diet. I have used Astra Garlic and Flavonex and Vein Lite but I still have swelling but the inflammation has gone down.
    PEOPLE’S PHARMACY RESPONSE: BLOOD CLOTS ARE SO SERIOUS THAT WE WOULD BE UNCOMFORTABLE SUGGESTING A HOME REMEDY.

  3. Christine G.
    Reply

    I am FURIOUS after reading this… as much with myself as the medical community! I worked as a paramedic and the procedure was considered “safe” and was an every day term. When my father was scheduled for one, I didn’t even think to research it first. How stupid could I be? I am now an herbalist and am kicking myself… got a cure for all these bruises?
    He is in prep… I hope I wasn’t too late in calling my mother to tell her to stop it. I also read about Enhanced external counterpulsation (EECP). Why isn’t the medical community doing more non invasive treatments? MONEY! They make me sick! For anyone smart enough to research BEFORE the procedure is being done, please look up EECP! GRRRR How could I be so stupid when it came to my own father?
    I KNOW BETTER THAN THIS! Sorry for the rant. I pray my mom could stop the procedure, but have a feeling it was too late. : (

  4. RCR
    Reply

    I’m a 39 year old male, in relatively good shape, not overweight mostly eat right, etc…
    Two weeks ago I had a heart attack… resulting from a 100% blocked RCA (Right Corodid Artery). The Dr.s saved my life using medicated stents. One in the RCA & two in the LAD. I thank God that this level of medical technology exists these days. Simply put, I alive because of it.
    Regardless of how much these medications or the procedures cost – it beats the alternative!
    My heart condition is due to heredity not ‘lifestyle’ or diet. We all have our crosses to bear. Just be happy you’re alive to bear it. Smile, close your eyes and take a deep breath… your alive.

  5. Greg Pharmacy Student
    Reply

    Carol S.,
    Try the Ornish Diet. Google it. It’s been studied and it works by reversing heart problems (unclogs arteries). It’s very strict, but rewards are priceless.

  6. Carol S.
    Reply

    I am glad to hear I am not the only one who is angry this morning. I had a stent implanted 3 days ago. Today I awoke with the same symptoms I’d been having for the past seven weeks. I saw my cardiologist for labored breathing, chest congestion, wheezing at night so bad I woke myself up and swelling in my legs and ankles.
    I had several tests (stress test, ultra-sounds etc.) Was it all for naught?!! I hate Plavix. I’ve seen what it does to people and cardiologist wants me to take it w aspirin too!! I’m furious and obviously still sick but from what? Does anyone know where I should go from here?

  7. Wes
    Reply

    I wish the study had measured some quality of life issues as well as “deaths, heart attacks or strokes”. Was there more limitation of activities of those on meds versus those on stents? If I could have a more active life with stents, then I would gladly pay the 15K out of my pocket. But if the stent did not allow a more active life then I could have spent the 15K on other things to help me enjoy that less active life.

  8. kg
    Reply

    I have one drug eluting stent in the diagonal and have been on plavix almost two and a half years. I am very afraid of a bleed in the brain or elsewhere. Very difficult to live with this worry as I have four friends now who were on plavix and had bleeds and several died. One is still in a nursing home trying to learn to walk, read and live again after a plavix bleed in the brain.
    There had to be a better, safer way. Any advice? How long are most major centers keeping their stent patients on plavix and exposing them to this risk?
    PEOPLE’S PHARMACY RESPONSE: THIS IS STILL BEING DEBATED BY CARDIOLOGISTS. IT IS CLEAR THAT PLAVIX IS NEEDED FOR AT LEAST A YEAR. IT IS NOT CLEAR HOW MUCH LONGER IT MIGHT BE NEEDED.

  9. S.H.
    Reply

    I wrote earlier and needed to add this info: after getting a stent with 40%, and the cardiologist telling me that my heart was healthy and they they usually did not put in stents with that low of blockage, and STILL BEING in pain after the stent, I went back to the ER 4 months later; a Dr. there diagnosed my serious case of gastritis and hiatal hernia, hooked me up to I.V.’s of two kinds of antibiotics and at least one acid blocker; the pain started going away and after a day or so, I never hurt again….(Nov. 2004) in that same spot I complained of over and over that was not heart related afterall; I am really upset over this; no insurance co will take me without rating me way up, and I will probably have to enter the insurance pool which will be horrid costs; the word stent has caused many companies to shy from me…. all because of a non necessary stent; now, they can be life savers, but for me, after reading this article, I am upset.

  10. Greg Pharmacy Student
    Reply

    Sue T,
    There is no such thing as a “free lunch”. The stent was a no cost to you, but it certainly was not free.
    It sounds like your heart condition is NOT what was described in the COURAGE study; yours is more serious and likely benefited from 2 stents.
    Metoprolol slows your heart so it does not require as much oxygen. Plavix and Coumadin prevent clot formation. Clots can block arteries and cause a heart attack. Plavix will have a generic in 2012.
    Take Plavix for at least 3 months if you have a bare metal stent or 12 months if you have a drug eluting stent. Many doctors recommend continuing Plavix for life.
    Meh: Taking oral Magnesium (glycinate or citrate or chelated) may also benefit A-fib. Ablation and surgically removing the Left Atrial Appendage may benefit A-Fib.

  11. meh
    Reply

    I am particularly interested in your comments about controlling your atrial fibrillation. My husband has just been told he has atrial fibrillation and has been put on coumadin with the comment he will be taking it for the rest of his life. He didn’t have any symptoms with the a-fib, he’s in very good health, exercises regularly and doesn’t take any other medications. I was completely unaware that it could possibly be controlled with diet but would certainly like to try.

  12. Greg Pharmacy Student
    Reply

    JB,
    1) The omeprazole and clopidogrel (Plavix) interaction has only been known for about 1 year. Your doctor may not have been aware.
    2)Your doctor also may be a skeptic of the interaction; the data to support the interaction is not concrete.
    3)Zantac (ranitidine) does not interact with clopidogrel.
    4) CoQ10 is usually given to decrease statin side-effects, NOT side-effects of Plavix.
    5) Report ALL side-effects to your doctor (WRITE THEM DOWN). Your doctor won’t fix something if it isn’t broken.

  13. Sue T
    Reply

    Hello. I am a Canadian woman of 57 years of age. I have had 2 stents inserted and it’s no surprise it didn’t cost me a dime being Canadian… however… I did have a heart attack on December 5th 2009, and was suffering with congestive heart failure for 2 weeks before I even went to emergency with the heart attack.
    I would consider that life threatening, and having to have something done (like stents) right away, and NOT just medication. I have been put on Plavix but also as a Canadian this does cost a small fortune!! I too want to quit taking this medication as I cannot afford it. I also take the Metoprolol and I was under the assumption that it does basically the same thing.
    Will I have trouble coming off of Plavix? Why did you write that this person’s father will have trouble coming off of the Plavix? Of course I will seek a doctors’ info before I go off of them, but was wondering if/why it would be hard to come off of them? I don’t want to jeopardize my health, but I cannot afford it either.
    PEOPLE’S PHARMACY RESPONSE: PLAVIX PREVENTS CLOTS FROM FORMING INSIDE THE STENT, OR ANYWHERE ELSE IN THE ARTERIES. METOPROLOL REGULATES HEART RHYTHM AND HELPS CONTROL BLOOD PRESSURE. SO YOU SEE THEY HAVE VERY DIFFERENT FUNCTIONS. YOU MUST CONSULT WITH YOUR CARDIOLOGIST BEFORE CHANGING ANY OF YOUR HEART MEDICATIONS.

  14. fbl
    Reply

    The shoulder harness damaged my heart during an auto accident four years ago and atrial fibrillation and a clogged LAD resulted. The cardiologist gave me no option but a stent. I chose to get chelation therapy with IV EDTA and that solved the blockage problem completely. My insurance company finally did reimburse me a little bit of the out-of-pocket expense too.
    No more blockage and I have since learned how to get the A-fibs under control. Increased minerals, digestive enzymes (particularly Betaine HCL) and reading food labels to eliminate all food additives-MSG, Aspertame, nitrates, sulfates, etc.

  15. JB
    Reply

    Thank-you for this insight. My father was on clopidogrel and omeprazole. During this last Christmas I found out that the FDA was saying not to take the omeprazole with the clopidorel anymore. It can actually diminish the benefits of clopidogrel by 50%. That is huge as far as I’m concerned. His cardiologist never mentioned it to him, didn’t even seem aware of this change.
    I immediately spoke with his doctor to have my father taken off it, at which point they offered a Zantac prescription, which we declined. I also found out that not everyone even needs the omeprazole, but in my father’s case they automatically put him on it after his heart attack in conjunction with his new prescriptions.
    He has now been off the omeprazole for almost 2 months. Aside from an increase in burping, he says he feels fine without it. Now we are adding CoQ10 to his regimen to try and combat his weakness and leg pain. Is it due to side effects or due to the clopidogrel effects being diminished? We don’t know. But after he’s been on the CoQ10 for a while we will start weaning him off the meds. My daughter loves her grandpa, so Mamma, we’re getting off this train . . .
    PEOPLE’S PHARMACY RESPONSE:
    We are glad you found out about the omeprazole-Plavix (clopidogrel) interaction. It is unlikely that your father will be able to stop the Plavix any time soon. If it can ever be discontinued it will have to be under the careful supervision of a cardiologist who has kept up with the medical literature.

  16. S.H.
    Reply

    I was angered by this article, mostly because I have a non-necessary stent! A few years ago I was under heavy stress with close family member deaths; I was having a hard time caring for a close relative living with us (who later died in our home); I had a very serious case of gastritis and hiatal hernia; my family doc did ekgs; all fine; I had a chemical stress test with a positive, but it did not show much at all. (AND I have since been told that people can have “false positives” with chemical stress tests).
    Because I was in lots of pain from the gastritis I went to ER; an angio showed barely 40%; I was sent to another hospital that went ahead and did a stent at 40% ! They even knocked loose some plaque and had to go digging around for it! It was painful; after the stent, the cardiologist came in and told me that I had a “healthy heart” and that they “usually didn’t put in stents with that LOW a per cent of blockage… but I was in pain and they went ahead with the plasty” He admitted that to me!
    Now, after reading the article in Peoples’ Pharmacy concerning stents, I KNOW I am upset! REALLY upset. My insurance was rated up because of an unnecessary stent; (had I just been put on statins, I’d still be able to get affordable insurance !!)

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