Painting: Singha Hon

Words: María Teresa Alzuru

When Senator Bernie Sanders had a heart attack last October, we read afterward that the presidential candidate had two stents placed in a blocked artery. Patients like Senator Sanders who have a sudden obstruction of a coronary artery (those that supply the heart itself with blood, oxygen, and nutrients) typically have an angioplasty, a procedure that opens up the clogged artery using a very small balloon inserted inside the blood vessel to remove plaque and open it up, along with the placement of a stent. Stents are tiny, wire mesh tubes that fit inside the blood vessel and hold it open. Often, they are also coated in medication that helps keep the artery open. In the case of a heart attack, where there is a suddenly obstructed artery, angioplasty and stenting can be life-saving. 

Recent evidence shows, however, that these interventions are often used unnecessarily on patients with stable coronary heart disease (CAD) where only a partial blockage develops and slowly over time. Patients with stable CAD may have no symptoms at all or they may have chest pain (referred to as angina) or shortness of breath. For those with symptomatic but stable CAD, doctors aim to relieve those symptoms and prevent the blockage from getting worse, causing a heart attack. For years, doctors have relieved these symptoms either by prescribing medications (you’ve probably heard of beta blockers or statins, for example) or by using interventions like angioplasty and stents (which are then followed by medication treatment).

A recent federal study known as the ISCHEMIA trial showed that patients who were treated using medication therapy alone versus those who received interventions like stents had no significant difference in outcomes. This means that neither group had more heart attacks than the other, nor did they die at higher rates.

Knowing that medication is just as effective as interventions in the case of stable CAD can save patients the anxiety of undergoing an invasive procedure as well as the exposure to new risks including the potential for heart attack, kidney failure, stroke, and bleeding. It can also save significant sums of money. As with any procedure, stent insertion can be incredibly expensive.  In 2019, Medicare spent over $10 billion on stent insertions. Something else to consider is that cardiologists, like most doctors, are paid on a fee-for-service model. This means that they make more money when they perform more procedures (in this case stent insertions). This can create a bias, even if unconscious, for leaning toward intervention over medication as treatment. 

Some cardiologists may also argue that stents are more effective at relieving chest pain (angina). However, a 2018 medical trial in Britain showed that this is largely due to placebo effect, not the stents themselves. The study compared patients who had stents placed with those who had a “sham” procedure where they were prepared for the stent insertion as usual, kept sedated for 15 minutes, but no stent was placed. Patients in the group that received stents and those in the placebo group had no difference in outcomes. So, rather than stents actually relieving pain, it is the placebo effect that has the most impact.

It is clear that there is a time and place for interventions in cases of acute coronary heart disease where time is of the essence. For people with stable, partial obstruction of the arteries, there are options to weigh. Some final things to consider: 

• If you choose to go with an intervention like a stent, you will still be required to take medications to ensure your heart stays healthy moving forward, but you will take fewer than if you opted for the medication-only route. 

• A healthy lifestyle can make a big impact when it comes to preventing and treating coronary artery disease. Quitting smoking, managing high blood pressure, high cholesterol and diabetes, staying physically active, eating a healthy diet, and reducing stress can all help keep your arteries strong and clear of plaque.