Stents are back in the news because of Bill Clinton’s cardiac “event.” Although the former president did not suffer a heart attack, discomfort and pressure in his chest prompted him to seek medical care.
He’d undergone quadruple bypass surgery in 2004, and the doctors who checked him over this time around found that one of those arteries had become completely blocked. That’s why they inserted a stent, a little wire mesh tube that is designed to hold an artery open.
Cardiologists are in agreement that stents can be extremely helpful if someone has severe heart disease like President Clinton. Stents can also preserve heart tissue and save lives if someone is having a heart attack.
What is not so obvious is the value of stents in many other situations. A study published in the New England Journal of Medicine (April 12, 2007) rattled the cardiology community to its core. Cardiologists are still arguing about the results.
The study, called COURAGE (for Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), pitted stents against drug therapy and lifestyle intervention. The 2,287 patients had stable coronary artery disease. That is, they had chest pain, but it was not of sudden onset or particularly worrisome.
Half of these patients were given stents together with drugs and lifestyle modification, while the other half got only the drugs with diet and exercise coaching. After five years, there were no statistical differences between the two groups with regard to deaths, heart attacks or strokes. There was, presumably, a big difference in price since each stent placement costs approximately $15,000.
The results astonished many cardiologists. The drugs used in the study cost far less than a stent and produced comparable benefit, although somewhat more slowly.
Experts expected the use of stents to drop dramatically after the COURAGE findings were published. It did for a while. But stent placement is now back to historic highs–nearly one million annually. If cardiologists followed the COURAGE guidelines, trying medical therapy first for patients with stable chest pain, they would put in one-third fewer stents. This could save an estimated $5 billion each year.
Some critics point out that stents have changed since the COURAGE trial was completed. Even the more modern drug-coated stents come with problems, however. Although they are less likely than bare metal stents to become clogged, they can lead to blood clots and heart attacks unless a patient continues taking an anticlotting drug like Plavix. A month’s prescription can cost over $160.
Plavix (clopidogrel) is not without side effects of its own. Serious bleeding is a constant worry. Digestive upset is fairly common, but the acid suppressing drug Prilosec (omeprazole) may reduce the effectiveness of Plavix. Other side effects may include headaches, skin reactions and blood disorders.
Stents save lives. But if a person is not having a life-threatening cardiac event, it may make sense to discuss medical management with a cardiologist first. COURAGE showed that for many people drug treatment together with diet and exercise can be as effective as a stent at a fraction of the cost.
