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Are Heart Stents Used Too Often?

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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About the Author
Terry Graedon, PhD, is a medical anthropologist and co-host of The People’s Pharmacy radio show, co-author of The People’s Pharmacy syndicated newspaper columns and numerous books, and co-founder of The People’s Pharmacy website. Terry taught in the Duke University School of Nursing and was an adjunct assistant professor in the Department of Anthropology. She is a Fellow of the Society of Applied Anthropology. Terry is one of the country's leading authorities on the science behind folk remedies. .
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comments (19 total)
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My mom recently had a stent implanted. She did not have a heart attack. She had severe aortic stenosis and that was corrected (supposedly temporarily) with a balloon angioplasty. I feel that the stent was unnecessary and just done to create more revenue for the hospital and doctor.

Since the major problem was the severe aortic stenosis, this procedure was unnecessary and now can cause more problems with taking Plavix and aspirin. I am, pretty much, fed up with the conventional medical community!

My mom recently had a stent implanted. She did not have a heart attack. She had severe aortic stenosis and that was correctly (supposedly temporarily) with a balloon angioplasty.

I feel that the stent was unnecessary and just done to create more revenue for the hospital and doctor. Since the major problem was the severe aortic stenosis, this procedure was unnecessary and now can cause more problems with taking Plavix and aspirin. I am, pretty much, fed up with the conventional medical community!

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.

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.

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. : (

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.

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.

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?

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.

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?

It depends on the type of DES, if it is a Promus Premier Everolimus-Eluting Platinum Chromium Coronary or (Everolimus-Eluting) stent you should have been able to come off a long time ago; as these stents give up there drug in the first 30 days allowing the epithelial lining (one cell thick lining of the artery wall) to rebuild. I would do some research. The reason for the long wait is the drug used to prevent restenosis of the artery also prevents the regrowth of the the epithelium. Your body looks at the damage from the stent like any other wall damage and tries to repair it with clotting.

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