Stents for blocked arteries versus medication and lifestyle changes

Stents for blocked arteries versus medication and lifestyle changes

One of the commonest procedures performed
around the world is called ‘stenting’. It’s where doctors open up a blocked artery in
the heart, and put in a little sliver of metal to keep it open. But there have been allegations
that far too many stents are being put in, when medications and lifestyle change could
do the job just as well, if not better. And in fact, a cardiologist in the United States
has recently been suspended for putting in too many stents. So what is the story here?
I spoke to a leading cardiologist, Associate Professor David Playford. Stenting in the setting of a heart attack
is beyond question. So nobody would ever argue, if somebody came in with symptoms consistent
with a heart attack, about going straight to the lab, getting pictures and fixing up
the artery as quickly as physically possible. In the setting of somebody who comes in with
unstable symptoms or even symptoms that have rapidly increased, again, opening the artery up
quickly is beyond question. The question comes in when somebody comes in with minimal symptoms,
or symptoms that are not clearly due to angina. And then looking for narrowed arteries, and
if you find one, then opening that artery up. There’s no evidence whatsoever that that’s
beneficial. If anything, there is evidence that that can cause harm. And then there’s this grey area called ‘stable
angina’. What is stable angina, and what’s the grey area? Stable angina is reproducible symptoms with
exercise. Which creep up on you. Right. It’s due to the progressive narrowing
of an artery that comes up over some time. Plaque or cholesterol deposition in the artery that
can slowly narrow it down to a point where there’s insufficient blood going through there
at times of stress. Usually there are no symptoms at rest because there is still enough flow
down the artery for the metabolic demands of the muscle. But with exercise, that fixed
narrowing doesn’t allow enough blood to go down there to meet the demands of the muscle,
and so that’s when the symptoms occur; with exercise. So a very important symptom with
stable angina is that it’s reproducible and occurs every time with the same level of exercise. And what you’re talking about mostly is chest
pain. It’s usually a discomfort, even the word ‘pain’
is not often used. It’s often across the chest, It may go up into the neck or the jaw or even
the teeth or the gums, and it can sometimes go down the left arm. It can be associated
with other symptoms like nausea and a bit of sweating, and often some breathlessness.
But those symptoms are classical, and a lot of people don’t have classical symptoms. Any
symptom that’s reproducible with exercise could be angina. So why are so many cardiologists putting in
stents for stable angina? The key issue here is in relation to the underlying
anatomy. If you’ve got stable or unstable anatomy — so if you come in with symptoms
that are reproducible and the same every time, or if you come in with symptoms that have
suddenly occurred or or suddenly worsened, or if you come in with a heart attack — underlying
there is still the same disease. It’s atherosclerosis. What atherosclerosis is,
is a slow and progressive development of cholesterol buildup within the wall of the artery, associated
with inflammation. So inflammation is an essential part of the process of development of atherosclerosis.
The artery initially starts out with this thing that we call a fatty streak, which is
really just that that the artery’s still the same size, there’s no narrowing of the size of the artery itself, the amount of blood going through is completely normal. But eventually as this progresses through,
you get the formation of actual plaque, which is cholesterol deposits within the artery
wall. It’s almost like a semi-liquid form associated with the inflammatory cells,
and it’s almost like a sore. It’s hot, it’s inflamed and it’s almost like it’s got a scab on the top of
it. And you still don’t know you’ve got it. So even though there may be a number of these
throughout the body, there may be a number in the coronary arteries, in the arteries
that supply the brain, you don’t know you’ve got it. And the scary thing about atherosclerosis
is that you may not have any knowledge that there is a problem until the first complication,
which could be a heart attack, or could be a stroke. And of course, the reason for talking about
the underlying causes is that the stent is more appropriate for one situation than the
other. Yet cardiologists are putting in stents for both. Stenting is a very effective treatment for
relieving angina. But what you’re doing by stenting is putting in a piece of metal. You’re
scaffolding this artery. And the scaffolding itself is not an inert substance. It’s like
a bare metal barrier inside this coronary artery. And the risk is that you could form
a blood clot on there, or that the scaffold can get covered over by tissue, and get ingrowth.
Now in order to stop the ingrowth new stents were developed which are called ‘drug-coated
stents’. They have this coating on the outside of the stent to stop the tissue from growing
back into it. The trouble with the drug-coated stents is that they are so effective in stopping
tissue growing into it that the tissue never grew in, so there’s this bare scaffold that
was exposed to the blood. And so if you stopped one of your medications to thin your blood,
there is a significant risk of developing sudden blockage of that stent, and a heart attack. If you’ve got stable symptoms, if they’ve
come on over a period of time and you’ve got what we call stable angina, most of the time
you don’t need a stent. But if you come in with sudden symptoms that have occurred at
rest, most of the time you do need a stent. Again, coming back to criticism of cardiologists,
is that they treat the artery and not the person. Because presumably, if you’ve got
one artery which is diseased, you’re going to have far more than that in your body, and
you’ll never have enough stents to be able to stent every artery that’s sick in your
body. What’s the story in terms of holistic care for somebody who’s got one artery that’s
gone wrong? Well, I think, the key thing is that you haven’t
just got one artery that’s gone wrong. In the situation of somebody who comes in with
symptoms of some sort, it doesn’t have to be angina or a heart attack, it could be a
stroke or a transient ischaemic attack, which is like a mini-stroke, or some other abnormality.
If there’s any symptom related to the vascular system, it means the problem is widespread,
Atherosclerosis doesn’t affect just that one artery and leave the others clean. All arteries
will be affected. So that means that whatever the process is that’s gone on to develop the narrowing
over the lifetime of this individual, we have to address everything in order to slow down
the process. And if anything, we try to stop the process getting any worse in the long
term. What has been very clear is that an improvement of weight, an improvement of diet,
an improvement of exercise levels, do actually make a difference in the long term. As well as reducing your cholesterol and taking
aspirin. Even if you can get good lifestyle changes,
there is very good evidence that long-term therapy, once you’ve got atherosclerosis,
you need the cholesterol lowering and you need the aspirin.

8 thoughts on “Stents for blocked arteries versus medication and lifestyle changes

  1. I lead a good lifestyle, exercised every day and ate right…still had a heart attack due to genetics and stress. I got stented…I take medication and still exercise and eat right. That little stent saved me.

  2. I just had a heart attack this past Sunday and one of my arteries was 100% clogged. The stent was put in and I can say it saved my life too. I am on a regiment of aspirin, statins and blood clotting blockers and I need to see how everything works out.

  3. Same here. I work hard, i run every day. I am 39 years old. I get physical checks yearly that are mandatory due to nature of my work, and had no anomaly found in 21 years of my work medical history. I am in great physical shape, and again, I fell down on the floor at my local bakery store due to sudden heart attack. Doctors saved me( Thank you, Dr. Blagica), did a crapload of tests, and everything is normal. I am scheduled for a coronography, and possibly a stent implant. Hope for the best.

  4. I have unstabe angina and my cardiologist gave me medications only but I wanted to have a stent to lessen up attacks because I still suffer chest discomforts almost everyday

  5. I had two stents in 2014, 5 months apart , then after the second stent while waiting for the site to cauterize , the nurses got me up to walk around before discharge and I told them of the weakness to my left side while walking, the head nurse said its from the anesthetic and discharged me to go home , only to come back later that night suffering from a stroke. I`m now going through several weeks of therapy thanks that nurse , keep this as a reminder !

  6. I just had a Heart Attack on Monday August 17th, happened at work. I got a stent the same day, so far so good, and need to exercise and eat well. Main arteries on heart was 100% blocked, Doctors said it should have killed me, God is good.

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