Inserting stents to open a blocked artery is a common way to treat coronary artery disease. But increasing evidence suggests the procedure is not as beneficial as patients and some doctors might believe.
An analysis published Monday in the Archives of Internal Medicine found that using stents to repair arteries narrowed by plaque was no better than using standard medications to treat patients with stable coronary artery disease.
Patients with the condition usually have angina, or chest pain, at certain times of physical activity or emotional stress. The pain is the result of blocked arteries, which can prevent adequate blood and oxygen from getting to the heart muscle, causing pain.
To relieve the condition, doctors will open the blockages with stents, metal mesh tubes that can be plain or coated with medication to keep the artery open.
Some recent analyses have pointed to the benefit of stents in treating coronary artery disease, but the authors of the current analysis point out that that data came from the 1980s and 1990s, when patients were often treated with balloon angioplasty rather than stents, and when modern drug treatments, such as statins, beta blockers and ACE inhibitors were not yet available.
"Medical management of coronary artery disease with aggressive statin therapy and other medications is much better now than it was in the past," said Dr. Jon Resar, director of interventional cardiology at Johns Hopkins Hospital in Baltimore.
But the popularity of stents persists, despite mounting evidence that less invasive, cheaper drug treatments are just as effective.
The current report analyzed eight clinical trials and a total of 7,229 patients, half of whom received stents and half of whom received medical therapy alone. The treatment outcomes were virtually the same for both groups: 8.9 percent of patients with stents died, compared with 9.1 percent of patients on medication only; 8.9 percent of the stent patients had nonfatal heart attacks, compared with 8.1 percent of the medicated patients.
Nearly 31 percent of patients who took medication eventually got a stent, and more than 21 percent of patients with one stent had to get another stent.
The results of the analysis don't come as a surprise to many cardiologists, who say the knowledge that stents aren't effective in preventing death or heart attacks is widespread. Many treatment guidelines already recommend giving medications to patients with coronary artery disease before turning to stents.
What is surprising, experts say, is that so many physicians continue to recommend and implant stents to treat stable coronary artery disease without first trying to treat patients with medication.
Dr. David Fischman, co-director of the cardiac catheterization lab at Thomas Jefferson University in Philadelphia, said there was never any evidence that they reduce the risk of death or prevent heart attacks in patients with stable disease.
"The knowledge, however, had gone unheeded by physicians and patients for a number of reasons," he said.
Some say the way the U.S. health care payment system encourages hospitals and doctors to perform revenue-generating procedures rather than prescribing medications. Procedures to insert stents can cost as much as $50,000.The authors of the current analysis estimate that avoiding stents by treating patients with medication only could save the health care system $9,450 per patient.
Resar said some cardiologists turned to stents in response to patients who want more aggressive solutions to their blocked arteries.
"Many patients just want a blockage fixed with a stent," Resar said. "Patients need to understand that simply putting in a stent in a blockage doesn't address the underlying problem. Lifestyle changes and aggressive medical management are far more important than just putting in a stent."
The analysis did note that stents were associated with a reduction in angina. Of patients who received stents, 29 percent still had persistent angina, versus 33 percent of patients treated with medical therapy alone.
Dr. Kirk Garratt, an interventional cardiologist at Lenox Hill Hospital in New York City, said those findings support the value of stents in improving the quality of life of patients who suffer from the disabling chest pain of angina.
"This means stents can help get more patients back to an active lifestyle, back to work, and closer to a normal life," he said. "The anti-angioplasty league says this means stents have no value, but I find support for the way we care for our patients."