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For years, patients with angina (chest pain) caused by blockages in the arteries have been treated with medications. When medications alone aren’t enough, cardiologists have turned to stents—small mesh or plastic tubes inserted into an artery to keep it open. However, a study published in The Lancet suggests that stents are not superior in alleviating chest pain when compared to drugs, which has patients and doctors alike questioning whether stents have a role in treatment plans for ongoing chest pain.
It’s troubling that this study is receiving so much press, because the main takeaway is not new: For most patients, medical treatment will respond to some degree of chest pain relief, but the best drugs in the world will not open the blockages. Stents do.
Stents aren’t the best treatment for everyone. This is a commonly known fact—as with any condition, there is no catch-all treatment for angina, which is caused by fatty plaque buildup that narrows the arteries and blocks blood flow (stenosis or atherosclerosis). But for someone with a severely blocked artery, a stent can stop their chest pain faster and lower the risk of reducing blood supply to the heart muscle.
Though the study may cause some people to question the need for stenting, I don’t foresee it making waves in cardiology due to a few concerning elements.
Concerns with the stents study
Three key issues about this study jumped out at me:
- The participant pool: With just 200 patients, the data pool is too small for the findings to be considered statistically significant.
- The timeline: Data were collected over six weeks, which is too short a window to draw solid conclusions in terms of risk reduction.
- Baseline: Patients at baseline were not that sick at baseline. Patients at the beginning of the study had a good exercise capacity, so it was not that hard to treat them with medications to improve their symptoms.
A better study, published in 2007, was the COURAGE study. It compared PCI, or percutaneous coronary intervention (angioplasty with stenting) to optimal medical therapy. The study was conducted over nearly five years with more than 2,200 patients and provided long-term, statistically relevant information. The study found that treatment with stents did not reduce the risk of death or heart attacks at five years, and medication alone was about as effective as medication plus PCI for the initial treatment of stable coronary artery disease. This does not mean PCI doesn’t work. Stents do reduce chest pain and are usually prescribed at MedStar Heart & Vascular Institute for patients who do not respond initially to medical therapy or when medication alone isn’t enough to control the disease symptoms.
Who is a good candidate for stents?
Many cardiologists, myself included, prescribe medication alone before recommending stents for patients who have moderately blocked arteries, minimal chest pain and a low risk for a heart attack in the near future. Some patients can safely choose between medication alone and medication plus a stent, depending on their symptoms and how blocked the artery has become. Often, these patients will opt for the stent.
But an artery that is 80 percent or more blocked is like a ticking time bomb in terms of heart attack risk. When a patient’s artery is that blocked, I don’t feel comfortable risking their life on medication that might not be effective on its own. In those cases, I’ll recommend a stent to reduce their risk of a cardiac event. We need to remember that drugs do not open the blockage and drugs may have side effects.
While not everyone needs or should have a stent, the study in The Lancet does not indicate that the therapy is ineffective. Rather, it illustrates the need for doctors and patients to work together to determine the most effective therapy for their unique condition instead of applying generalized standards to everyone’s care. If you have a stent and are concerned, or if you’re thinking about getting one, call 703-552-4036 for an appointment with one of our MedStar Heart & Vascular Institute cardiologists.