Making sense of stents

August 8, 2011

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While the rates of angioplasty with stent insertion have come down in recent years, too many patients with stable heart disease are still having the procedure unnecessarily. Patients considering this therapy should ask their doctor these questions:

Am I already on optimal medical therapy? Only 40 to 60 percent of those with heart disease are getting the medications they need to prevent heart attacks, such as statins, baby aspirin, and beta blockers, according to Dr. Michael Lauer, a cardiologist and director of the division of cardiovascular sciences at the National Heart, Lung, and Blood Institute. Unless symptoms cannot be controlled, optimal drug therapy should be tried before any vascular intervention in those with stable disease.

Why are you recommending the procedure? Angioplasty with stents can be lifesaving for patients who have had a heart attack in the last few hours or have unstable angina that could lead to a heart attack. There's no evidence to suggest it can provide more than symptom relief in those who arenot in an emergency situation. It's still not known, however, whether patients with an abnormal stress test that indicates reduced blood flowto the heart—called ischemia—experience fewer deaths and heart attacks after undergoing angioplasty. "That's something we're planning to investigate in a clinical trial nowgetting underway,'' said Lauer. Aremysymptoms severe enough to warrant the intervention? Many symptom-free patients with clogged arteries should not be having angioplasty, said Lauer. Those with ischemia or who have chronic chest pain or breathlessness that is severely interfering with their quality of life and not well managed with medications such as beta blockers might be good candidates for the procedure.

What type of stent should I have? About 25 percent of the time, bare-metal stents lead to new blockages that require a repeat procedure. Drug-eluting stents, which release a drug to keep the artery from closing again, reduce the risk of this problem, but are associated with blood clots. "Those who get a drug-eluting stent must be willing to be on two platelet-blocking drugs, like aspirin and clopidogrel, for at least a year,'' said Lauer, to avoid clots. Is bypass surgery a better option? Patients with significant plaque in their left main coronary artery or in multiple arteriesmay be better candidates for bypass, according to Lauer. And research suggests diabetes patients have better outcomes with bypass surgery than with stents in terms of future heart attacks and survival rates. DEBORAH KOTZ

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