Do You Really Need A Stent?

Three Questions To Ask Your Doctor

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We have all heard the claims that cardiologists are inserting too many stents in patients with coronary artery disease (CAD). And the fact is that this happens much more often than we would like to think.

So what should you do if your doctor says you need a stent? Are you one of those people who actually do need a stent - or should your doctor be talking to you about medical therapy instead?

    If your doctor tells you that you need a stent, it is likely he or she will attempt to explain why. But the issue can be quite complicated, and your doctor may not be entirely clear in his/her explanation. And you may be too stunned by the news that you need a stent to concentrate completely on what you are being told.

    Fortunately, if your doctor says you need a stent, there are three simple questions you can ask which will tell you what you really need to know. If you ask these three questions, you stand a much better chance of getting a stent only if you really need one.

    Question One: Am I Having A Heart Attack?

    If you are in the early stages of an acute heart attack, the immediate insertion of a stent can stop the damage to your heart muscle, and can help reduce your chances of suffering cardiac disability or death. If the answer to this question is "yes," then a stent is a very good idea.

    No need to go on to Question Two.

    Question Two: Do I Have Unstable Angina?

    Unstable angina, like an actual heart attack, is a form of acute coronary syndrome (ACS) - and therefore it should be considered a medical emergency. The early insertion of a stent can stabilize the ruptured plaque that is producing the emergency, and can improve your outcome.

    If the answer to this question is "yes," placing a stent is most likely the right thing to do. No need to go on to Question Three.

    Question Three: Isn't There Medical Therapy I Can Try First?

    If you get to Question Three, it means that you are not having an acute heart attack or unstable angina. In other words, it means you have stable CAD. So, at the very least, placing a stent is not something that needs to be done right away. You have time to think about it, and to consider your options.

    It is the patients with stable CAD who, according to the best clinical evidence available, are receiving far too many stents. In stable CAD, stents turn out to be very good at relieving angina, but they do not prevent heart attacks or reduce the risk of cardiac death. So, the only really good reason to insert stents in people with stable CAD is to relieve persistent angina when aggressive treatment with medication fails to do so.

    The Best Approach For Stable CAD

    The best treatment for people with stable CAD is to take every step that is available to stabilize plaques in the coronary arteries -- that is, to keep the plaques from rupturing.

    (It is the rupture of a plaque that produces ACS in the first place).

    Stabilizing plaques requires the control of cholesterolblood pressure, and inflammation, no smoking, regular exercise, and making clotting less likely. Aggressive drug therapy will include aspirinstatinsbeta blockers, and blood pressure medication (when necessary). If you are having angina, adding nitratescalcium channel blockers, and/or ranolazine will usually control the symptoms.

    If your angina persists despite this kind of aggressive medical therapy, then by all means a stent is something that should be strongly considered. But keep in mind that a stent only treats one particular plaque, and that most people with CAD have several plaques. Furthermore, while most of these plaques are considered "insignificant" by traditional measures (since they are not producing much blockage in the artery), it now appears that the majority of cases of ACS occur when one of these "insignificant" plaques suddenly ruptures.

    What this means is that, whether or not you end up getting a stent for your stable CAD, you still will need aggressive medical therapy to prevent the rupture of one of those "other" plaques, the "insignificant" ones, the ones for which too many cardiologists may express little or no interest.

    Summary

    If you are told you need a stent, you can quickly determine how badly you need one, if at all, by asking three simple questions. These questions are so easy for your doctor to answer - generally with a simple yes or no - that there will be no excuse for his/her failing to take them up with you.

    But if it turns out that you have stable CAD, and therefore a stent is at least not an emergency, you are owed a full discussion about all your treatment options before you are pressured into a stent.

    Source:

    Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354.

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