Sunday, February 26, 2012

Overuse of Cardiac Stents

One of my patients is in the hospital in another city (where he lives part of the year) after suffering a GI bleed.  He had a black stool, had lost blood, was quite anemic and experienced weakness and chest tightening before he came to the ER.   In the emergency room his Cardiologist was called and admitted him under the cardiology service.  When I called the Cardiologist to identify myself as his Internist, he told me the patient was getting a transfusion and he wanted to do an angiogram to see if his prior stents were open and possibly put in more stents. 

What?  Stop right there.

The patient has chronic renal failure,  has low blood counts, was quite stable with no symptoms, was receiving a transfusion and the cardiologist wants to put in stents?  There are so many things wrong with this story I wanted to scream.

First of all, the workup should first zero in on the GI tract and find out why the patient had lost blood.  He was not experiencing any chest pain or tightness once he received blood and was feeling quite normal.  The cardiologist didn't even seem to be considering what the cause of the anemia was and had not called in a GI consultant.  Additionally, with compromised kidney function, an angiogram could put him into acute renal failure:

"Contrast nephropathy is a recognized complication after coronary angiography and intervention that has been associated with prolonged hospitalization and adverse clinical outcomes," write lead study author Jay Kay, MBBS, MRCP, from the University of Hong Kong in Aberdeen, and colleagues.

 Not only was the workup and plan completely wrong, but I wanted to ask the cardiologist if he was even aware of the COURAGE study that has rocked the medical world.  This large trial was published in The New England Journal of Medicine and presented at the 2007 Scientific Session of the American College of Cardiology.  The results showed there was no difference in the outcome (death or new non fatal heart attack) between patients with stable angina who received cardiac stents and those who did not.

Every patient is different and large trials like COURAGE give us information with which to make decisions.  Most patients think stents save their lives.  Most patients have never heard of these trials and still depend upon their physician to make the decision about what is needed.     In this case, the Cardiologist was making a really bad decision for my patient.

As the Internist, I am looking at the entire picture and trying to be the quarterback.  I respect the roles of the receiver, the half back and the guards but each of them are looking only at one part of the play, while I am viewing the entire field.  In this case a patient with a GI bleed (later found to be an ulcer), no signs of unstable angina and chronic renal failure should NOT have an angiogram or any invasive cardiac procedure.

I advised my patient to "just say no".  When he did, the Cardiologist replied, "Don't blame me if you go home tomorrow and have a heart attack."

Just jaw dropping!


Anonymous said...

This is a truly frightening story. I hope your patient appreciated your involvement. How can patients ever be sure that what is being told to us is right?

Jacqueline Castro said...

Good for you!!!!!

Ada Beth Harris said...

Fascinating! As a recipient of a stent in 2011, one wonders whether I would have had it placed if I'd had my coronary event in 2008! Good info for all of us to know. Proves the value of having a really good quarterback on your team!

Ada Beth Harris said...

Oops! I meant to state that I had a stent placed in 2001! Makes a difference, since we didn't know about the COURAGE study back then. Sorry for the type!

Raymond Bouchayer said...


Toni Brayer, MD said...

Ada Beth Harris: Please don't misunderstand. A stent that is placed in an emergency or heart attack situation with PCI (percutaneous coronary intervention)is very different than placing stents for non-acute angina. Your stent in 2001 was most likely necessary and good medical practice.

Michael Kirsch, M.D. said...

My reaction to this post is SPOT ON!

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Anonymous said...

We can assume that the increase in death in those with chronic stable angina is plaque rupture and thrombosis of the coronary artery.

We can also be sure that the factors that influence plaque rupture like thickness of the fibrous cap are currently not able to be screened, partially because of a lack of technology and partially because pathologists, those with the knowledge to use and develop this technology, refuse to because they are not very bright, competent, or ambitious.

So the results of the trial aren't surprising. If you open a clogged vessel, you will get symptomatic relief (the COURAGE trial says that). But you cannot predict which of the plaques will blow; a minimally stenotic plaque might be the one most in danger of causing thrombosis.

The study basically rules out chronic stable angina having any effect on long-term cardiac survival.

Otherwise, its not big news.