Stents – One Size Doesn’t Fit All

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PCI (percutaneous intervention) is a treatment for angina, or chest pain. A million Americans a year get this treatment, which involves inflating a balloon to clear a blocked artery and implanting a small mesh cylinder (stent) to hold it open.  But does PCI do any good?  Not according to a new study, which appears to show that PCI is no better than pharmaceutical treatment for “stable” angina – transient chest pain associated with stress or exercise.

As reported in the New York Times, “The researchers reviewed eight randomized trials comparing PCI with standard medical care. Combining data from all the studies, the researchers found that prescribing beta blockers, ACE inhibitors, statins and daily aspirin — now standard for treatment of stable coronary artery disease — was just as effective as stent implantation for prevention of chest pain, heart attack, the need for a future PCI and death.”

This conclusion comes as no surprise to Cleveland Clinic cardiologist, Stephen Ellis, MD.  “We’ve long recognized that medicines rather than PCI are the best protection against heart attack for stable patients,” says Dr. Ellis. “We also know that for another category of patients, those who are unstable and threatened with heart attack, PCI is better than medicines.”

More controversial is Stony Brook’s finding that the chest pain didn’t go away for 29-33 percent of patients who had either medicine or PCI. Dr. Ellis has problems with this conclusion, as well as the study’s methodology.

“The study purports to show that PCI doesn’t even prevent angina in these patients, but the analysis doesn’t stand up to close reading,” he says. “It would have been more instructive if the study had provided results based on the patients’ initial level of angina. At least a third of patients in these studies had no or minimal angina to start with, as physicians in general are reluctant to possibly randomize highly symptomatic patients to medical therapy alone. Not surprisingly, medicines alone were able to keep angina at bay in these patients. Second, these studies enrolled patients 1997-2005, so in some cases stents weren’t even used. Finally, almost no patients received drug-eluting stents, which are known to reocclude 70-80 percent less frequently than after balloon angioplasty or non-drug-eluting stents.

Dr. Ellis points out that PCI reduced recurrent angina by a nearly-statistically significant 21 percent in the study. Other studies have shown a greater reduction when angina is more severe to begin with.

“Cardiologists know that contemporary stents have a limited role for treatment of patients with limited symptoms,” says Dr. Ellis. “However, for patients with lifestyle-limiting angina that is resistant to medical therapy, stents can — and do — safely relieve symptoms.”