Providers Remain Too Much in Love with Angioplasty and Stents

Although some people in cardiac distress need invasive procedures to survive, some heart treatments are overused, and the cost continues to mount.

As explained by patient safety advocate John James in his August newsletter, performing angiography on and inserting stents in patients with stable heart disease not only wastes money, but can be unsafe.

An angiogram is an X-ray of blood vessels made visible after the patient is injected with radioactive dye. It’s often prescribed to detect damaged blood vessels and problems affecting blood flow. After an angiogram locates an occluded coronary artery, a stent, or tiny, self-inflating tube can be inserted to open it, and keep it open.

James claimed that “It has been well known for almost a decade that stenting coronary arteries in stable patients is not in the best interest of the patient,” referring to research in the New England Journal of Medicine. He noted that cardiologists have been prosecuted for performing this needless procedure, and that people have died from it.

Still, they’re widely performed, as we have noted, often because providers find them so profitable.

James also reported that many cardiologists fail to fully inform their patients about the value of angiography and stent placement. Apart from the standard risks of invasive procedures, such as pain, bleeding and infection, you’re exposed to radiation; the more images you receive by technology such as CT and MRI scans, the more radiation you receive, and all such exposure is cumulative.

James recounted the story of a middle-aged man who went to an ER after one episode of chest pain (angina). He had felt rushed and uninformed about his situation, and was told by a cardiologist and another physician that he should have a stent inserted to unblock his arteries. He consulted another cardiologist for a second opinion, who prescribed medication and dietary changes (optimal therapy), telling the patient that there was no scientific evidence that invasive procedures such as stents would benefit him. Indeed, the man was much improved within three months.

A study in JAMA Internal Medicine last month looked at the quality of information cardiologists gave to their heart patients whose condition was stable. Only 59 such discussions were reviewed, but the pattern was clear – only about two conversations involving 23 different cardiologists included all seven elements of informed consent. And when those standards were somewhat relaxed, still only about 8 encounters were considered complete. “Overall,” wrote James, “the decision to have angiography with possible stent insertion was inversely correlated with the number of elements of informed consent given by the cardiologist. Optimal medical therapy alone is known to benefit patients, yet this option was not discussed in [3 in 4] encounters.”

If you have heart issues, and your doctor thinks you might be a candidate for one of these procedures, ask as many questions as you need to feel fully informed about the diagnosis, whether it’s considered stable and what are all the risks and benefits of any treatment. Get a second or third opinion if you need to. As James suggested, “Always frame your questioning in terms of your fears rather than in terms of your mistrust of the provider.”

For more information, see the explanation of angioplasty and stent placement published by Johns Hopkins.

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