Whether a stent is needed can be tough call

When patients are in the throes of a heart attack, there's no question that stents save lives.

But for heart patients with few symptoms and less than severe artery blockage, whether to use a stent is a question with no clear-cut answer, say cardiologists. In fact, these days some heart experts say the mesh metal tubes used to keep narrowed or weakened arteries propped open are overused for blockages that can be treated just as well with medicine, a healthy diet and exercise.

A recent internal review of heart patients at St. Joseph Medical Center in Towson, Md., found 369 patients received the coronary implants unnecessarily. Those findings have sparked one lawsuit so far and threats of more to come — while highlighting a debate among cardiologists and confusion among patients over when stents are necessary.

So, what's a patient to do? For those in the middle of a heart attack with unrelenting symptoms, stents are the best option, cardiologists say. But for others, the answers can vary.

"It's not black and white," said Dr. Mark Hlatky, a professor of cardiovascular medicine at Stanford University. "This is a whole shade of gray."

The key for patients is education. Understand your test results, know the options available and ask plenty of questions of your doctor well before you undergo any procedures, cardiologists advise.

Stents are typically placed in an artery after an angioplasty, a procedure in which clogged vessels are cleared with a balloon to restore blood flow to the heart. Stents act as scaffolding, keeping the arteries pushed open so they can stay clear for years after the procedure.

In the 1990s, coronary artery stents were welcomed by doctors and patients alike, offering a less invasive, cheaper alternative to bypass surgery, and an option more effective than angioplasty on its own. Since then, about 1 million stents have been implanted each year in the United States.

But they don't come without risks. Patients must be on blood-thinning medication for a year or longer. There's a risk of complications during stent placement and beyond, including blood clots and heart attack. Once they're put in, stents can't come out.

In recent years, clinical trials have shown medication to be as effective in some circumstances, and an internal debate has been brewing over whether doctors rely too heavily on the implants.

Stents only relieve symptoms; they don't make you live longer, Hlatky said, adding that he falls on the conservative side of the debate. The first question any physician and patient should ask is if interventions are needed at all or whether a person's symptoms could be helped with drugs alone, he said.

If an intervention is needed, the second question should be what kind: a stent or bypass surgery, he said. Bypass surgery is usually reserved for patients with more extensive heart disease and multiple severe blockages, while stents work best for patients with one or two blockages, he said.

"The strategy should be, let's try drugs first," Hlatky said. "If they work, we'll keep using them. If they are not working and you keep having symptoms, we'll go ahead and use an angioplasty (and stent). But this should not be routine for anyone."

Dr. Monica Aggarwal, a noninvasive cardiologist at Mercy Medical Center, agrees stents should only be used when medicine and lifestyle changes have failed. When a patient comes to her with chest pain, Aggarwal must figure out if it's cardiac pain or something else such as heartburn, muscle pain or a lung problem.

"A patient should be asking: What are my symptoms, are they cardiac or not? What are my risk factors?" she said.

If symptoms indicate pain is coming from the heart, a doctor typically orders a stress test, which evaluates how well the heart is working after exercise. Some stress tests can tell where on the heart that blood flow is stalled.

If the test is abnormal or shows blood flow is restricted in important areas, then a doctor and patient should discuss the options.

"(Patients) should ask, do we need a stress test? What is the stress test looking for?" said Dr. Claudia Hochberg, an interventional cardiologist at Boston Medical Center. "And then, afterward, what kind of abnormality is found? What's the best way to treat it?"

A normal test may simply require more monitoring. Even with an abnormal result, a patient might do well with medicine and a change in lifestyle, such as quitting smoking, eating better and exercising, she said.

When a stress test reveals that more than one vessel is restricted or blood flow is blocked in a major artery branch on the left side of the heart, most cardiologists will take a closer look to determine how bad the clog is, using cardiac catheterization. In that procedure, a tool is inserted in the leg and threaded up to the heart, Hochberg said.

If the arteries are very clogged, most doctors put in a stent.

But before catheterization, patients and doctors should discuss the options, Hlatky said. When a doctor does the test and finds a significant blockage, most stents are placed immediately, during the same procedure. If a patient has reservations about having a stent put in, at that point, it's too late to discuss them, he said.

"You don't have a lot of time to reflect on this," he said. "The doctor sits there and says, 'I can do this now,' and they do. It's important to have the conversation beforehand."

But for some patients, these steps don't always unfold easily. Determining the severity of a blocked artery isn't an exact science, said Dr. Jon Resar, an interventional cardiologist and director of the adult cardiac catheterization laboratory at Johns Hopkins Hospital.

By clinical guidelines, an artery should be clogged at least 70 percent before a stent should be placed, Resar said. "A 50 percent blockage doesn't need to be stented," he said. "Give them Lipitor, control their blood pressure and have them exercise." But often, catheterization and a coronary angiogram, which takes pictures of the heart vessels, give a doctor a range of a blockage, not an exact number, he said. That wiggle room leaves the decision to use a stent in the hands of the cardiologist doing the procedure, making the device susceptible to overuse, he said.

"There are a lot of intermediate blockages that shouldn't be stented but end up being stented primarily because of financial incentive to the physicians who get paid for doing the procedure," Resar said.

Stents are big business for hospitals, which can charge $10,000 or more for the process.

Some insurance carriers are pushing for more stringent justification of stents, Resar said. Techniques that can help include using a pressure wire to help measure whether blockages are significant enough to warrant a stent, he said.

"Then you're not doing unnecessary procedures and not putting stents where they don't need to be," he said. "And you're decreasing costs by only treating blockages that need to be treated."

Still, whether to insert a stent can be a tough call for even the most ethical of clinicians, Aggarwal said.

"Nobody wants to miss heart disease," she said. "It's the No. 1 cause of death in men and women. There may be more aggressiveness on invasive testing because we want to make the right decision for the patient.

"It's not that bad cardiology is being practiced, it's not that we're not making good decisions," she added. "It's just not always clear."

Since a 2007 clinical trial found that drug therapy is often as effective as stents, cardiologists have been re-evaluating the use of the implants, Aggarwal said.

"That was a turning point for us," she said. "We stepped back and said, gosh, medical therapy is really great. Before, you see a blockage, you stent it. It works. It seemed so obvious. But it was a good opportunity for us to step back and say maybe we aren't giving enough consideration to medical therapy."

And even if a patient does end up getting a stent, that shouldn't be seen as the cure-all for a heart problem, Aggarwal said. Exercising, eating a healthful diet and quitting smoking are still crucial.

"Getting any procedure on your heart doesn't give you a free pass to not take care of yourself," she said.