I am an interventional cardiologist and admit to placing thousands and thousands of stents in heart arteries. But results from a study—called the ORBITA trial—made headlines (like this one: “‘Unbelievable’: Heart Stents Fail to Ease Chest Pain”) in the New York Times. Personally, I have felt for a long time too many stents have been placed. But before we go into the controversy, let’s back up and talk about the study, how it was designed, and what it really proves—or disproves:
First, what is chronic stable angina?
After 30 years of practicing cardiology, I’ve found that chronic stable angina, which is the condition that stents are commonly used to treat—is a relatively uncommon finding in patients. It usually presents with patient complaints about tightness and pressure in their mid-chest during periods of activity. I often hear, “Doctor, when I walk the treadmill at 2 mph I feel fine, but when I elevate it to 3 mph I sense a tightness or pressure in my mid chest.” That is chronic stable angina and usually indicates a severely blocked heart artery, but the risk of imminent heart attack is not high.
How was the study designed—and what does it really show?
The results of the ORBITA trial were presented and published in full this week. A group of 200 patients with chronic stable angina and at least one artery blocked at least 70 percent on a catheterization were treated with optimal medication and then were brought back to the catheterization laboratory for a procedure up to the heart. Half had a sham procedure where no stent was inserted, and half got a stent. The patients and doctors were not told whether a stent had been placed, and the medications at discharge included the blood thinners required for stents—whether they had been inserted or not. At six weeks a stress test and questionnaires were repeated to compare to those taken before the study.
The principal finding was that there was no significant change in the primary outcome, which was a change in exercise time from baseline for stent versus the sham treatment. The results also showed no significant change in angina severity score or physical limitation and no significant change in angina frequency from baseline versus sham.
So, are stents worthless?
No! But it’s clear that way too many heart stents have been placed. In fact, cardiologists have even gone to jail for Medicare fraud, as placing stents is a profitable business. It’s simply important to make sure that they are really needed, and different treatment options must be fairly and openly presented. Over the last 20-plus years, heart stents have represented a major breakthrough in patient care that has saved many lives and avoided the much more invasive and risky heart bypass surgeries.
However, studies dating back at least a decade point to the fact that stents for those with no symptoms or with stable heart symptoms are usually not indicated. Emphasis on medication and, even more importantly, lifestyle measures shown to prevent and reverse existing blockage, are still not given to patients and are seldom presented as an option to stents and bypass surgery.
Do patients have other options?
For decades, I’ve presented my patients with three doors: Door one is a whole foods, plant-based diet, exercise, and stress management. Door two is a stent, and door three is bypass surgery. Many have picked door No. 1 and have never had stents or bypass and are doing great. Furthermore, many of them have shown documented evidence of reversing their blockages, which should be the standard, not the rare type of practice I founded.
The bottom line: Question, get second opinions, and always ask why. Cardiologists are in a position of power and have more knowledge than most patients, which can be used to make both good and bad recommendations. There is almost always time to get a second opinion and to read about heart disease prevention and lifestyle change programs for patients with chronic stable angina.