To stent or not to stent for chest pain?

“‘Unbelievable’: Heart stents fail to ease chest pain” was the sensational headline in the New York Times on Thursday, sparking a heated debate among doctors about their go-to treatment for angina — pain in the chest caused by blocked arteries.

The safety of stents was not challenged. They’re still considered to be quite safe. But do they work any better than drugs to relieve chest pain? Maybe not.

The study published in The Lancet found that three different interventions — drugs, stenting, and even a sham procedure tricking people into thinking they had a stent — all had patients reporting improvements in their chest pain.

Almost immediately, experts started pointing out weaknesses in the methodology — the study was short, just six weeks, and small, with just 200 patients.

It was the sound of a medical doctrine being challenged once again.

“Through my training as a cardiologist this has been dogma,” said Dr. Sacha Bhatia, a cardiologist at Women’s College Research Institute in Toronto. “If an artery is blocked we should open it because that’s going to improve blood flow to the muscle and improve patient outcomes and improve symptoms.”

He stresses this debate is not about people who are having heart attacks or have unstable disease. But, for patients with stable conditions who want relief from chest pains, the new study will make some cardiologists think twice.

Normally if a patient shows up with a blocked artery and chest pain, Bhatia would recommend putting in a wire mesh stent to open up the blood vessel and improve the blood flow.

“Now we might pause and take the patient off the table and have a discussion with the patient,” he said. “Try pills first to see if symptoms will go away and if you can tolerate the medication. We can say that both options will provide similar pain relief.”

The patient would then have to weigh the risks of the stent procedure versus the side-effects of pills.

And because the new study used a sham procedure on some patients, tricking them into thinking they’d had a stent, it raised the disturbing question of placebo effect. How much of the pain relief from stents is due to the mysterious tendency for patients to feel better just by believing they’ve been treated?

An accompanying commentary in The Lancet said the study highlights the need for rigorous testing of all surgical procedures before they’re widely adopted.

But what does this mean for people who go to their cardiologist for treatment of angina pain? Those patients now have a choice, Bhatia said.

“The options are not so straightforward anymore as ‘I’ve got angina and I need to get a stent.’ It’s not a one-size-fits-all approach anymore.”

It’s not the first time the widespread use of stents has been questioned. Back in 2007 a major study made front-page news when it showed no difference between stents and drugs in preventing death from heart attacks.

Since then, several cardiology associations have narrowed their recommendations about when to use the stenting procedure, known as percutaneous coronary intervention (PCI).
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Photo credit: Lightspring/Shutterstock

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