Rethinking Stents: When They Help, When Medications Work, and What Patients Should Ask

Welcome to another episode of Cardiovascular Therapeutics Unplugged. Today Dr. Mehra pulls back the curtain on one of cardiology’s most common and most misunderstood procedures: the coronary stent. When a stress test comes back abnormal, “stent” is often the word that follows, and for many patients, it sounds urgent and final. But is it always the right move? In this episode, we confront the myths and explore the evidence, showing when a stent can save a life, when medication is just as effective, and how to cut through fear to ask the questions that matter most. If you or someone you love has ever been told you need a stent, this is the episode you cannot afford to miss.

00:00 How stents work in arteries

06:50 Stent decision criteria and FFR

09:12 Understanding heart attacks and treatments

12:21 Discussing the Courage trial results

16:20 Heart attack interventions and treatments

19:26 Using medical therapy for heart disease

23:51 Discussing procedure risks with patients

27:12 Discussing second opinions with patients

29:44 Talking with cardiologist about options

32:46 The benefits of patient involvement

Transcript

SPEAKER_01 0:00

Every invasive procedure carries with it an inherent risk and could have serious bleeding complications. You can have a stroke, you can have a heart attack. The patient is right there. You have the tools in your hand, and there's a natural cognitive pull to intervene on the patient. This is what's called commission bias and the tendency to act rather than withhold action, especially in this procedural environment. The field of cardiology started questioning the need of stenting everybody with an anatomic lesion on their cardiocathorization. You're doing evidence-based interventions. We're not just stenting a blockage out seeing a blockage. An acute blockage, what we call a STEMI or an ST elevation MI, means that a plaque is ruptured and it needs to be treated immediately. What happens is that plaque rupture happens, the body tries to heal that area of plaque rupture and forms what's called an acute thrombus and shuts down the vessel in that area by forming a clock. You either get a complete occlusion or near complete occlusion, and the heart muscle starts dying in that in that territory where that artery supplies blood. And this is literally the urgent heart attack, the classic heart attack that you hear about. That's an ST elevation MI. And here, time is muscle. So we need to intervene quickly. We go in there and we try to open up the blockage within 90 minutes from when the patient presented to the ER door. This is where intervention with the stent has no ambiguity. We go in there and open up the blockage. Stable angina, on the other hand, what leads to elective interventions, is a completely different physiologic animal. It is chronic, the plaque is fibrotic in nature, it is less likely to rupture like an acute plaque in an ST elevation MI, but it's slow buildup of plaque that leads to the narrowing of the blood vessel. That leads to symptomology that we talked about, chest discomfort, shortness of breath, on exertion, climbing stairs, doing grocery shopping. This leads to, this is the definition of stable angina. And it's relieved with rest or taking nitroglycerin. So here the heart is experiencing transient decreased blood flow or reversible ischemia. So it is important that to make that distinction and understand what's going on. And in these patients, about 10 to 15% of these patients will have a risk of acute cornea syndrome or black rupture in the future. Now that again has to be a nuanced approach, and that's where we consider all aspects to see whether a patient needs an intervention or not.

SPEAKER_00 3:14

And then you just I think touched on this, but so the courage and the ischemia trials shifted a lot of clinical thinking around sensing for stable disease. So what did those studies actually show and how did it change your own practice?

SPEAKER_01 3:28

Yeah, these trials were very big in the world of uh cardiology and interventional cardiology. And these were landmark studies that honestly humbled a lot of us in in in interventional cardiology as we were really touting the benefits of stenting. And so it it took us back and made us look at the fundamentals of stable coronary disease. So let's talk about the Curse trial. The Courage trial was a large trial of over 2,200 patients that was published in the New England Journal of Medicine in the year 2007. And it basically enrolled patients with stable angina and documented coronary disease and randomized them to medical therapy versus uh intervention, percutaneous intervention with a stent, plus optimal medical therapy. And essentially, over over the course of almost five years, there was no significant difference in the primary endpoint of death or non-fatal myocardial infarction in the PCI of percutaneous intervention group plus optimal medical therapy versus just medical therapy. So the difference was in the functional status of the patients where they initially, the people who got the stent had better symptom relief. But by three years, that also disappeared as the medications were optimized. So that showed us that treating stable angina medically is actually very, very important. Looking at a lesion and stenting and looking at a stable lesion and just stenting it is not the answer. So it gives you a little bit of a pause. So that was the courage trial that put the brakes on just unnecessary stenting in patients. The other one was the ischemia trial that was published a little later in 2019, and that had over 5,000 patients. And it was essentially looking at patients who had moderate to severe ischemia with stress testing, meaning that they had a defect and a positive stress test, and they randomized them to invasive therapy, which is stenting versus the conservative medical therapy alone. And then again, over three years, there was no significant difference in primary composite outcome of heart attack and cardiovascular death. And that's where kind of like the interventionalists started the field of cardiology started questioning the need of stenting everybody with an anatomic lesion on their cardiocathy. What changed for me personally is that now I essentially have these nuanced conversations with the patients in a lot more detail. Not just say that you need a stent. I tell them about why it is important to be on the right medications before we go and stent. I audit my own practice differently. I ask myself whether the medications have really been optimized before I explicitly, you know, go ahead and stent somebody for their coronary artery disease.

SPEAKER_00 6:22

And then you touched on sometimes a stent is the right answer and sometimes it's not. But when is a stent unambiguously the right call? No debate, no waiting. When is it clear that that's the right move?

SPEAKER_01 6:33

Like I said, in a heart attack, period. And somebody is having a heart attack for SD elevation MI, it's called primary PCI, a primary percutaneous intervention. It reduces the mortality by approximately 25% compared to just thrombolytic therapy or blood anti-clotting agents or anti-thrombotics. This has been shown in multiple trials in the past, and there is no debate in this setting when somebody's having a heart attack, every minute of delay and not intervening percutaneously, it is the right call without any question. Beyond acute myocardial infarction or ST elevation MI, left main, which is the main artery that supplies the blood to the front of the heart and the lateral part of the heart, the left main corneary disease, uh, if that has a significant stenosis, no, and it's it's got blockage to the extent where you might think that it might be life-threatening, stenting that showed mortality outcomes were better at five years in a couple of trials. So either you could go for revascularization with bypass surgery in that case, or with stenting, but that's an important setting as well. Third setting where you have multivessel disease, all three arteries of the heart are severely blocked, and your heart function is significantly compromised, in that area, the stenting or surgery, again, bypass surgery or multivessel stenting, depending on the anatomy and what's called the syntax scores, uh, you know, revascularization has shown mortality benefits. So those are essentially the three areas. Now, if somebody's having unstable angina or non-ST elevation MI with hemodynamic instability or elevated cardiac enzymes, again, early invasive strategy has shown to reduce recurrent ischemic events. So these are very, very nuanced situations, and it's important to understand what you're dealing with in your specific clinical scenario. Broadly, any unstable situation, stenting helps. Any stable coronary disease, you want to optimize medical therapy and then consider stenting for symptom relief if you've optimized your medications and you're still having compromise in somebody's functional stance.

SPEAKER_00 8:45

And then speaking about medicine and on the flip side of when you need a stent, when does evidence really say that medication alone is just as effective or the right call for certain scenarios? Can you kind of walk us through what that scenario would be like?

SPEAKER_01 8:59

For stable single vessel or even multivessel disease in a patient where symptoms are controlled, symptoms are well managed. What's called ischemic burden on a stress test or non-invasive imaging is moderate. There is evidence from these two trials, like encouraged and the ischemia trial, that optimal medical therapy performs as well as for cutaneous sediments in terms of heart outcomes, such as death and myocardial infarction. And these trials are aggressive. Optimal medical therapy means optimizing medical therapy where high-intensity statins have to be given to target your bad cholesterol, the LDL, to less than 70 milligrams per deciliter. You want to have adequate blood pressure control with beta blockers and ACE inhibitors and anti-texinal receptive blockers. In some cases, uh patients have to be on anti-anginal agents such as renolazine for refractory angina. So these are all the pharmacologic active treatments that modify plaque biology and reduce cardiovascular risk. So these trials showed us that, you know, aggressive optimal medical therapy is equivalent. So that's what we are.

SPEAKER_00 10:07

And then I don't know if there's truth to this, but is there truth to the idea that more sense sometimes happens because it's easier to act than to have a longer, more in-depth conversation about certain alternatives at all?

SPEAKER_01 10:19

I'll be candid. Yeah. There's an element of truth to that that our field has had to genuinely reckon with that. It it really depends on a variety of different factors like the individual operator or cardiologist's training, keeping up with the guidelines, understanding the differences between unstable situations versus stable coronary plaque. Um for interventional cardiologists, the way we train in these high adrenaline situations, yeah, we become your mind becomes attuned to looking at stenosis and finding it easy to just go ahead and fix it. And and and it is an equivalent therapy, but again, it has downstream effects. It's great. So sometimes, yes, it is easier to just go ahead and look at that vivid image of a narrowed artery on a screen. The patient is right there, you have the tools in your hand, and there's a natural cognitive pull to intervene on the patient. This is what's called commission bias, and the tendency to act rather than withhold action, especially in this procedural environment, is uh is became the norm. But having more and more evidence, more and more stuff coming out, which changes your practice, forces you to rethink everything. So, yeah, I mean, it's driven by your individual training, it's driven by the guidelines, it's driven by your local culture, it's driven by your education, it's driven by reimbursement in some cases. So you have to really make your decision based on more and more tools that we have in the CAT lab, like the FFR that I mentioned. So more and more appropriate use criteria is being touted. We are doing evidence-based interventions. We're not just stenting a blockage after seeing a blockage.

SPEAKER_00 12:10

Interesting. And so, what are some of the real risks of a stent that patients don't usually hear about going into this? So, not to really scare them, but just so that they really understand that trade-off.

SPEAKER_01 12:21

A lot of these things, a lot of procedures have become routine. Every invasive procedure carries with it an inherent risk, and and it's the job of the interventional cardiologist or to really discuss the possibilities and the side effects or the complications that could happen with with the procedure, just like any any proceduralist needs to do for their procedure. For us, it's easy because we do a lot of these, but for that patient, the risks are not 1% if something goes wrong. The risk is 100% if something goes wrong. I have these discussions with my patients every time I discuss a procedure, they need to have. Strokes are very, very rare, 0.1 to 0.2%. There's also the risk of what's called contrast-induced nephropathy, the contrast dye that we use can hurt the kidneys. So that is a real concern in patients who might have some baseline kidney dysfunction or diabetes. So we focus on hydrating those patients really well so that they can essentially urinate the dye out over the next 24 to 48 hours. Yeah, those are those are essentially the most common side effects. The other side effects are come downstream because if you do get a stent, you get placed on certain blood thinners. Most commonly aspirin and clavics or aspirin and prolinta or tachydrolore for a period of six to twelve months. And those things can cause increased bleeding risk. Also, once you place a stent, you have to discuss the possibility of buildup of black within those stents in the future, and then requiring repeat procedures. So it's something to consider. Those are essentially the most complications or side effects that we discuss.

SPEAKER_00 14:38

So if a patient gets a stunt recommendation and thinks that they want a second opinion before agreeing to move forward, what would you recommend that they ask? What should they ask their provider and who should they ask it to, actually?

SPEAKER_01 14:51

I mean, it that really depends on your particular clinical situation. If you have a long-term relationship with the patient, they will trust you. If you're seeing somebody for the first time and I'm talking to them, obviously in the setting of a heart attack, there's no time for second opinions. But if they are a relatively new patient and they want to get a second opinion, I encourage them to get a second opinion for elective procedures. I actively encourage it if they if they have any doubts. But hopefully, if you're going through all the possible scenarios and risks and benefits and alternatives and and the data and the evidence and having a shared decision-making process with an informed patient, they usually don't need a second opinion because the first opinion is significantly informative. I try to tell them that even if I do find a blockage, we can study them from the inside with things like a fractional flow reserve and see if it's requires intervention. Also, if they have multivessal disease, I talk to them about the possibility of needing bypass or things like that. So I encourage them to ask questions about understanding what the disease burden is, what medications they might have to take, what the complications are going to be possibly, what is the risk, how well trained the interventionalist is, who's doing the procedure on them, you know, asking what happens after the procedure. These are things I expect from the patient, and I try to volunteer as much of this information as possible so that they they don't feel like they're lacking information.

SPEAKER_00 16:31

Absolutely. And then speaking about questions, let's say for someone who is sitting in a cardiologist's office now hearing the words you need a stunt for the first time, what's the one question that really cuts through the fear and gets to what actually matters?

SPEAKER_01 16:44

Yeah, so I mean, it's tough to say what's the one question. If you are having a conversation with your cardiologist about usually this conversation arises from somebody complaining about chest discomfort or somebody having an abnormal stress test. These are the two most common things. So most of the time you've had a non-invasive test, either a cardiac CAT scan, which shows coronary plaque, or a calcium score that's abnormal or an abnormal stress test, where you're sitting down with your cardiologist and they're saying you need a cardiac atherization and possibly a stent. One of the questions I tell my patients that's important to ask or think about is if I don't have a cardiac catharization or stent, what is my possible outcome? And is there an alternative we can try first? And that single question will encompass a lot of the nuanced conversation that I talked about, nuanced things that I talked about earlier. Then we automatically get into the fact that we need to optimize your medical therapy. This is the risk of a procedure, this is what we want to do to modify your 10-year, 20-year risk. And if you don't have an intervention without the stent, is there a possibility of your heart muscle dying if this blockage is significant enough to compromise blood flow in the future? So these are the things that I mentioned. Most of the time, like I said, there was improvement in symptoms based on all our studies with procutaneous intervention or stent. So even with optimal medical therapy, there might be persistence of symptoms and compromise of functional status. So that is something that I want the patient to understand.

SPEAKER_00 18:30

Absolutely. And I think one key takeaway that I learned in this episode is that a stent isn't a verdict. It's one tool used at the right moment for the right problem. And knowing the difference between this can really save your life, and this is one option among several. Maybe one of the most important conversations a patient has before ever having to reach the cath lab. So if you've been told that you need a stent, don't fear, make and don't let fear make that decision for you. Ask the questions, understand the why, and make the choice with your eyes open. Thank you so much, Dr. Mara. This is another great episode of Cardiovascular Therapeutics Unplugged. For everyone listening, make sure you follow, share, and subscribe so you don't miss another good conversation. And it was a pleasure speaking to you as always. Before we wrap up, is there anything else you wanted to add in?

SPEAKER_01 19:13

I just want to add that the best physicians in the world in our field welcome these questions. And it's easier for me to have an educated, informed patient when I make these clinical decisions to intervene upon somebody because it makes for a better doctor, it makes for a better patient when the data is consistently discussed with them. It leads to better adherence with medication after we put in a stent, when the patient is informed and they participated in the decision-making process. And it overall makes for better satisfaction, greater satisfaction with the decision that we made together if both of us are on the same page.

SPEAKER_00 19:56

Absolutely. And definitely, even these conversations are so helpful for patients to be able to hear this from you and really learn the differences and have that knowledge before going into these conversations at a cardiologist's office or if they've been recently told they need a stent or things like that. These conversations are so helpful. So again, thank you as always. Another great episode, and I can't wait to talk to you soon.

SPEAKER_01 20:18

All right. Thanks, Layla.