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When and why should patients get a coronary stent?

Medical studies spanning years and examining thousands of patients have upturned conventional thinking about heart attack prevention and treatment. The studies found that for many patients, coronary stents are not more likely to save lives or prevent a heart attack than medication and lifestyle changes. Yet some patients are not given the opportunity to weigh the risks and benefits of various treatment options.

Regulators for the California Department of Public Health discovered that “there was no consent for placing stents” in William “Ned” Smith, 72, who died after the procedure. Nor was there an emergency need for the procedure, regulators concluded.

His case is one of several highlighted in an investigation of heart care at Desert Valley Hospital, a facility owned by Prime Healthcare.

Physicians typically place stents after performing an angiography, or an imaging procedure to inject dye into the coronary arteries to see whether vessels are blocked. In some cases, physicians thread a tiny tube through an artery in the groin or wrist and then inflate a tiny balloon. That balloon expands a small wire-mesh tube that’s meant to facilitate the flow of blood through the blocked artery.

Physicians agree that placing a stent within 90 minutes of a heart attack is beneficial to patients. They differ when it comes to patients who suffer from milder discomfort that comes with physical activity.

Here are some considerations to mull, based on a conversation with Dr. John Wong, the medical editor for coronary artery disease at the Informed Medical Decision Foundation. Wong is also chief of the Division of Clinical Decision Making, Informatics, and Telemedicine at Tufts Medical Center in Boston.

When is a stent elective?

Wong said a stent is considered elective, or a matter of patient preference, when a patient suffers from stable angina. That condition is characterized by pressure or pain in the chest during physical exertion or emotional strain. Stable angina symptoms tend to go away when the physical or emotional stress has passed.

What are the risks of getting a stent for stable angina?

According to Wong, elective stent placements carry a risk of death for 6 to 7 people out of 1,000. Complications include heart attack and artery perforation. Risk of death may be higher if you’re older, have diabetes, heart failure, kidney disease, or have more than a few vessels blocked.

A data analysis by the California Office of Statewide Health and Planning and Development showed that for 2009 inpatient cases, about 2 out of 100 patients died during hospital stays when a stent was placed. That data does not account for whether the patient had stable angina or a more dire condition.

What are the benefits?

Wong said that one study showed that coronary stents relieve the pain and pressure of angina more quickly than an approach of taking medications, exercising and improving one’s diet. However, that study found that in the long run, there was little difference in heart attack or mortality rates between those who had elective stents and those who pursued medical therapy and lifestyle changes.

What is the bottom line?

Wong said patients with stable angina should weigh the benefits and risks of both approaches and make a decision that fits best with their lifestyle.

“Some important questions are how much does the angina bother you, and does it bother you enough that you’d consider the potential harms,” he said.

What about getting a stent in a hospital with a catheterization lab versus one with open-heart surgery?

In California, nearly 60 hospitals have a cardiac catheterization lab that allows them to place stents in emergencies, such as after a heart attack, when a patient has pain that doesn’t subside with treatment or amid major swings in blood pressure. Those labs are meant for diagnostics, not treatments. A group of California cardiologists is currently studying whether the state should allow stents in those hospitals, as many other states currently do. That team is expected to send a report to lawmakers.

Hospitals licensed to perform open-heart surgeries have teams and equipment to crack open the chest and operate. If a stent procedure leads to a complication, such as major bleeding from a tear in an artery, those hospitals are best equipped to save patients.

Where else can I obtain information?

Emily Bazar with the Center for Health Reporting wrote guides about when elective angiography is appropriate and described a variety of heart procedures.

Health Dialog publishes a decision-making guide for patients who are diagnosed with coronary heart disease.

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