Cardiologist Richard Fogoros — aka DrRich — has put out an incredibly timely and pertinent piece of advice concerning the common practice of stenting blockages in the coronary arteries.
He succinctly summarizes a small retrospective study that showed an increased risk of cardiac events after non-cardiac surgery in patients who have recently undergone either a bare metal or drug-eluting coronary stent.
On a website clearly designed to educate patients, DrRich rightly points out that patients should–unless in an emergency situation–“discuss all the other options of therapy for a partial obstruction of a coronary blockage.”
Incredibly sound advice indeed.
I believe the stent story needs to be told.
What DrRich implies with his sage advice is that just because a blockage exists; that we see it visually, does not mean that it needs to be squished open with a metal scaffolding. Placing metal in a squished blockage improves the physics of flow, but in doing so places a foreign, and often sticky metal scaffolding in close proximity to blood. After a stent is placed the words, “you are fixed,” is often said. This is not really correct, as the disease of diminished flow is traded for two new ailments: the disease of a foreign body in contact with blood, and the disease of dependence on a blood thinner, often forever.
Then there is the not so unimportant issue of pre-condtioning. Not much is said of this important phenomenon. I think of it as follows: the long-term partial obstruction exposes the downstream heart muscle to chronic deprivation of nutrients. This in turn causes adaptations leading to collateral vessel growth and a heartiness, a resistance to the effects of a total blockage. There are few positives about chronic blockages, but this conditioning effect is clearly a protective mechanism. Contrast this with the stented (0% blockage) artery. No blockage means no adaptations are made, and when a total blockage of the stent–say from thrombosis (clotting) of the stent–occurs, the heart misbehaves badly, often resulting in major heart damage or sudden death.
A trade-off for sure. The good and the bad. Physics are improved, but risk is enhanced.
With this sobering introduction, let’s enter the post-surgical arena, which for recent stent patients off plavix, is a highly volatile mixture. Why? A post-op patient is by definition, a stressed patient. The body is inflamed, adrenaline levels are high, and the coagulation cascade is turned to “high.” The cut-on body is in healing mode. By definition, blood thinners have to be withheld so as to avoid the risk of excess bleeding. It makes perfect sense that cardiac events rates in patients with squished blockages and metal scaffold are higher after surgery.
The real disease here is atherosclerosis–hardening of the arteries or disease of the endothelium. It should be known that stents treat symptoms of the disease; only symptoms, not the disease. In the smooshing process, symptoms like chest pain or shortness of breath are lessened, but the disease remains. Heart attack, strokes and sudden death are not reduced by coronary stents. In fact, in the post-op soup, or for that matter, many other stressful stimuli, like forgetting to take one’s plavix, catastrophic events may be more likely in the patient previously considered “fixed” by stents.
Americans want an easy fix for their blockages. On the surface, stents seem to fill this void. The dye injected after the skillfully deployed stent shows a wonderful smoothness: “80% reduced to 0%,” reads the report. But the disease remains.
Angioplasty and stents have saved many from the throws of heart attack and near certain death; this is true. The “squishers” do this regardless of the clock face. These are heroic deeds worthy of praise. In bike speak, “epic” is a frequent adjective. Additionally, stents can be deployed in numerous blood vessels, and in doing so can often preclude the need for open heart surgery. This is really great as well.
Unfortunately though, stents are neither a fix, nor a cure for the real disease at hand, atherosclerosis. The real treatment is hard to administer. It takes will and strength to circle the dessert bar and still say no to the ice cream lever, to ride the bike or walk the park each day, to go to sleep each night at the right time, and to live life devoid of the inflammatory effects of anger. These are the real treatments–the program. Many study the program, know the program, but cannot seem to implement it.
Stents do not replace the program. Sadly, this news doesn’t sell so well.
John Mandrola is a cardiologist who blogs at Dr John M.
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