7 ms·

Heart Stents Fail to Ease Chest Pain

62 points by denzil_correa 9y ago

bluetwo 9y ago
Previous research showed that stents increase lifespan only in patients who have already had a heart attack.
graeham 9y ago
Stents are an incredible piece of engineering, but probably are over-used (particularly in the USA). There are a few issues at play: -Chest pain -Artery narrowing -Heart attack risk They aren't the same, although there is correlation between each. The original idea behind stents was to stabilise vessels in the process of a heart attack. They are increasingly used in a preventative way - but the problem is there aren't very many or good tools to tell how at risk an individual is to a heart attack. Another major problem (as the article mentions) is that stents improve the situation in one artery, but most patients that need a stent have atherosclerosis in multiple vessels. This likely explains why the chest pain remains.
- epmaybe 9y ago
  I'm a little confused by this. Patients can get stents in multiple arteries during one cath lab session. Generally it's a diagnostic cath at first, finding all blockages, and deciding which vessels should be ballooned/stented. I've been in multiple procedures (shadowing, not performing) where they did 2+ vessels.
  - graeham 9y ago
    Agreed that multiple stents and multiple vessels can be stented in one cath session. My point was more that there isn't very strong evidence or criteria for what constitutes a vessel that should be stented versus which should not. Worse, plaques are dynamic – what looks benign today could rupture and cause a complete/near occlusion. Rupture and subsequent thrombosis is more dangerous than stenosis itself.
mcguire 9y ago
"For the study [...] recruited 200 patients with a profoundly blocked coronary artery and chest pain severe enough to limit physical activity, common reasons for inserting a stent. "All were treated for six weeks with drugs to reduce the risk of a heart attack, like aspirin, a statin and a blood pressure drug, as well as medications that relieve chest pain by slowing the heart or opening blood vessels. "Then the subjects had a procedure: a real or fake insertion of a stent. This is one of the few studies in cardiology in which a sham procedure was given to controls who were then compared to patients receiving the actual treatment. "In both groups, doctors threaded a catheter through the groin or wrist of the patient and, with X-ray guidance, up to the blocked artery. Once the catheter reached the blockage, the doctor inserted a stent or, if the patient was getting the sham procedure, simply pulled the catheter out." I would really like to know how they got that study past the assorted ethics committees.
- amelius 9y ago
  I guess the patients knew they were taking part in an experiment, and got paid for it.
- trevyn 9y ago
  "Stenting is so accepted that American cardiologists said they were amazed ethics boards agreed to a study with a sham control group. But in the United Kingdom, said Dr. Davies, getting approval for the study was not so difficult. Neither was it difficult to find patients. “There are many people who are open to research, and if you tell them you are exploring a question, people agree,” he said. Nonetheless, it took him three and a half years to find the subjects for his study. Ethics boards at many American hospitals probably would resist, since giving such patients fake procedures “flies in the face of guidelines,” Dr. Boden said."
  - jogjayr 9y ago
    In a practical sense, I wonder how they'd successfully do it in the US. Stents cost on the order of $11k-$44k per the article. Wouldn't you just know from looking at your bill afterward whether you got the stent or not?
tomohawk 9y ago
They only assessed the patients after 6 weeks. It would be interesting what a longer follow up of the patients would reveal.
thomastjeffery 9y ago
A 6-week study of 200 people. Why is this news?
- pak 9y ago
  Well, for starters, it's hard to get 200 people who might be eligible for life-preserving surgery to volunteer to possibly get a sham procedure for the exclusive benefit of othewars; not to mention build a team of surgeons, hospitals, etc. willing to do the trial; and someone to pay for millions of dollars in treatment and administrative costs. Clinical trials involving surgery, especially with sham procedures as a proper control, are exceedingly rare in the US for these reasons. (this is discussed in the OP itself.)
- s0rce 9y ago
  Not to mention the difficult of finding patients for surgical trials, especially of relatively pre-existing procedures, the cost per procedure could be (conservatively) $10k making this still a $2M study.
- starchild_3001 9y ago
  I once read a study that the half life of truth in medicine is 20 years. Namely in 20 years roughly half of the things we identified as truth are overturned. Examples? Fat clogs arteries. Cholesterol clogs arteries. LDL causes heart disease. High blood pressure causes atherosclerosis. All of these "truths" have been debunked in the last 30 years or so. Apparently there are many more. Stents save lives? There's 50% chance you'll be proven wrong in ~20 years! Maybe much sooner.
  - trhway 9y ago
    >I once read a study that the half life of truth in medicine is 20 years. i heard that as a joke - Medical school dean to his graduates : "A half of the things we taught you will be proven wrong in 5 years. We just don't know which half."
  - robbiep 9y ago
    When I was at med school 7 years ago we were told for years. I thought it was just a way of saying that medical knowledge increases so quickly, but then whilst I was there we had: - Total change in how we manage chest pain/heart attacks (moving from previous full/partial thickness infarction to STEMI/NSTEMI and totally revising treatment algorithms - Introduction of ipilumimab for melanoma (changed metastatic melanoma from a condition with 6 month average survival to 5 years/chronic disease - Introduction of cure for help c (previously followed the rule of 20 and it was a chronic disease) - Total revision of food pyramid - Multitude others I believe 4-6 years. So much changes, without CPD/CME you are useless.

62 points by denzil_correa 9y ago

Previous research showed that stents increase lifespan only in patients who have already had a heart attack.

Stents are an incredible piece of engineering, but probably are over-used (particularly in the USA). There are a few issues at play: -Chest pain -Artery narrowing -Heart attack risk They aren't the same, although there is correlation between each. The original idea behind stents was to stabilise vessels in the process of a heart attack. They are increasingly used in a preventative way - but the problem is there aren't very many or good tools to tell how at risk an individual is to a heart attack. Another major problem (as the article mentions) is that stents improve the situation in one artery, but most patients that need a stent have atherosclerosis in multiple vessels. This likely explains why the chest pain remains.

epmaybe 9y ago
I'm a little confused by this. Patients can get stents in multiple arteries during one cath lab session. Generally it's a diagnostic cath at first, finding all blockages, and deciding which vessels should be ballooned/stented. I've been in multiple procedures (shadowing, not performing) where they did 2+ vessels.
- graeham 9y ago
  Agreed that multiple stents and multiple vessels can be stented in one cath session. My point was more that there isn't very strong evidence or criteria for what constitutes a vessel that should be stented versus which should not. Worse, plaques are dynamic – what looks benign today could rupture and cause a complete/near occlusion. Rupture and subsequent thrombosis is more dangerous than stenosis itself.

mcguire 9y ago

"For the study [...] recruited 200 patients with a profoundly blocked coronary artery and chest pain severe enough to limit physical activity, common reasons for inserting a stent. "All were treated for six weeks with drugs to reduce the risk of a heart attack, like aspirin, a statin and a blood pressure drug, as well as medications that relieve chest pain by slowing the heart or opening blood vessels. "Then the subjects had a procedure: a real or fake insertion of a stent. This is one of the few studies in cardiology in which a sham procedure was given to controls who were then compared to patients receiving the actual treatment. "In both groups, doctors threaded a catheter through the groin or wrist of the patient and, with X-ray guidance, up to the blocked artery. Once the catheter reached the blockage, the doctor inserted a stent or, if the patient was getting the sham procedure, simply pulled the catheter out." I would really like to know how they got that study past the assorted ethics committees.

amelius 9y ago
I guess the patients knew they were taking part in an experiment, and got paid for it.
trevyn 9y ago
"Stenting is so accepted that American cardiologists said they were amazed ethics boards agreed to a study with a sham control group. But in the United Kingdom, said Dr. Davies, getting approval for the study was not so difficult. Neither was it difficult to find patients. “There are many people who are open to research, and if you tell them you are exploring a question, people agree,” he said. Nonetheless, it took him three and a half years to find the subjects for his study. Ethics boards at many American hospitals probably would resist, since giving such patients fake procedures “flies in the face of guidelines,” Dr. Boden said."
- jogjayr 9y ago
  In a practical sense, I wonder how they'd successfully do it in the US. Stents cost on the order of $11k-$44k per the article. Wouldn't you just know from looking at your bill afterward whether you got the stent or not?

tomohawk 9y ago

They only assessed the patients after 6 weeks. It would be interesting what a longer follow up of the patients would reveal.

thomastjeffery 9y ago

A 6-week study of 200 people. Why is this news?

pak 9y ago
Well, for starters, it's hard to get 200 people who might be eligible for life-preserving surgery to volunteer to possibly get a sham procedure for the exclusive benefit of othewars; not to mention build a team of surgeons, hospitals, etc. willing to do the trial; and someone to pay for millions of dollars in treatment and administrative costs. Clinical trials involving surgery, especially with sham procedures as a proper control, are exceedingly rare in the US for these reasons. (this is discussed in the OP itself.)
s0rce 9y ago
Not to mention the difficult of finding patients for surgical trials, especially of relatively pre-existing procedures, the cost per procedure could be (conservatively) $10k making this still a $2M study.
starchild_3001 9y ago
I once read a study that the half life of truth in medicine is 20 years. Namely in 20 years roughly half of the things we identified as truth are overturned. Examples? Fat clogs arteries. Cholesterol clogs arteries. LDL causes heart disease. High blood pressure causes atherosclerosis. All of these "truths" have been debunked in the last 30 years or so. Apparently there are many more. Stents save lives? There's 50% chance you'll be proven wrong in ~20 years! Maybe much sooner.
- trhway 9y ago
  >I once read a study that the half life of truth in medicine is 20 years. i heard that as a joke - Medical school dean to his graduates : "A half of the things we taught you will be proven wrong in 5 years. We just don't know which half."
- robbiep 9y ago
  When I was at med school 7 years ago we were told for years. I thought it was just a way of saying that medical knowledge increases so quickly, but then whilst I was there we had: - Total change in how we manage chest pain/heart attacks (moving from previous full/partial thickness infarction to STEMI/NSTEMI and totally revising treatment algorithms - Introduction of ipilumimab for melanoma (changed metastatic melanoma from a condition with 6 month average survival to 5 years/chronic disease - Introduction of cure for help c (previously followed the rule of 20 and it was a chronic disease) - Total revision of food pyramid - Multitude others I believe 4-6 years. So much changes, without CPD/CME you are useless.