This is the single most important distinction in modern cardiology, and almost no patient has it explained to them.
During a heart attack, an artery is blocked, heart muscle is dying, and every minute counts. Opening that artery with a stent saves lives. This is one of medicine’s genuine triumphs, and nothing below applies to it.
Electively, for stable disease, the situation is entirely different. A patient has chest pain with exertion, or an abnormal stress test, or a calcium score that prompted an angiogram. A narrowing is found. A stent is placed. The patient is told the blockage has been fixed.
The trials do not support the conclusion most patients draw from that experience.
COURAGE compared stenting plus medical therapy against medical therapy alone in stable coronary disease and found no reduction in death or heart attack. ORBITA compared stenting against a placebo procedure — patients sedated, catheter inserted, no stent placed — and the difference in exercise time between the groups was not what anyone expected. ISCHEMIA, the largest of the three, randomized thousands of patients with moderate-to-severe ischemia and again found no reduction in death or heart attack from an invasive strategy.
Stents do relieve angina in many patients, and that is a real benefit for someone whose life is limited by symptoms. But relieving symptoms and preventing heart attacks are different claims, and patients are rarely told which one they’re buying.
Why the intuition is so strong
Because the picture is compelling. You see the narrowing, then you see it open, and it looks like a plumbing problem solved.
The trouble is that heart attacks usually don’t happen at the site of the tightest narrowing. They happen when a softer, inflamed, non-obstructive plaque ruptures and a clot forms on top of it. Those plaques are scattered throughout the arteries. Stenting the one that happens to be narrowest doesn’t address them.
That’s the whole argument for treating the disease diffusely — the inflammation, the insulin resistance, the ApoB, the blood pressure, the diet, the movement — rather than treating one spot.
What I tell patients
If you’re having a heart attack, go. Don’t think about any of this.
If you’re stable and someone is recommending an elective stent, it’s fair to ask three questions. What specifically will this do for me — relieve symptoms, or prevent a heart attack? What does the evidence show for someone in my situation? And what happens if we optimize everything else aggressively first and reassess?
Those are reasonable questions. A good interventionalist won’t mind them.
Andrew Rudin, MD is a cardiologist and board-certified cardiac electrophysiologist who takes a natural, root-cause approach to heart health. He sees telehealth patients nationally and internationally through Natural Heart Doctor, and is licensed in New York and Tennessee. He has been quoted as an expert source by Medscape and Men’s Journal, and was profiled in The Village Voice. More at andrewrudinmd.com.
This article is for general education and is not medical advice. It is not a substitute for care from your own physician, and nothing here should be used to start, stop, or change treatment on your own.