Do You Really Need a Stent for CAD?

We have all heard the claims that cardiologists are inserting too many stents in patients with coronary artery disease (CAD). And, the fact is, this happens much more often than we would like to think.

So, what should you do if your healthcare provider says you need a stent? Are you one of those people who actually does need a stent—or should your practitioner be talking to you about medical therapy instead?

If your healthcare provider tells you that you need a stent, it is likely he or she will attempt to explain why. But the issue can be quite complicated, and your healthcare provider may not be entirely clear in his/her explanation. You may be too stunned by the news to concentrate completely on what you are being told.

Fortunately, if your practitioner recommends a stent, there are three simple questions you can ask which will tell you what you really need to know. If you ask these three questions, you stand a much better chance of getting a stent only if you really need one.

Are You Having a Heart Attack?

If you are in the early stages of an acute heart attack, the immediate insertion of a stent can stop the damage to your heart muscle and can help reduce your chances of suffering cardiac disability or death. If the answer to this question is "yes," then a stent is a very good idea. No need to go on to Question Two.

Do You Have an Unstable Angina?

Unstable angina, like an actual heart attack, is a form of an acute coronary syndrome (ACS)—and therefore it should be considered a medical emergency. The early insertion of a stent can stabilize the ruptured plaque that is producing the emergency and can improve your outcome. If the answer to this question is "yes," placing a stent is most likely the right thing to do. No need to go on to Question Three.

Isn't There Medical Therapy You Can Try First?

If you get to Question Three, it means that you are not having an acute heart attack or unstable angina. In other words, it means you have a stable CAD. So, at the very least, placing a stent is not something that needs to be done right away. You have time to think about it and to consider your options.

It is the patients with stable CAD who, according to the best clinical evidence available, are receiving far too many stents. In stable CAD, stents turn out to be very good at relieving angina, but they do not prevent heart attacks or reduce the risk of cardiac death. So, the only really good reason to insert stents in people with stable CAD is to relieve persistent angina when aggressive treatment with medication fails to do so.

The Best Approach for Stable CAD

The best treatment for people with stable CAD is to take every step that is available to stabilize plaques in the coronary arteries—that is, to keep the plaques from rupturing. (It is the rupture of a plaque that produces ACS in the first place.)

Stabilizing plaques requires the control of cholesterol, blood pressure, and inflammation, no smoking, regular exercise, and making clotting less likely. Aggressive drug therapy will include aspirin, statins, beta-blockers, and blood pressure medication (when necessary). If you are having angina, adding nitrates, calcium channel blockers, and/or ranolazine will usually control the symptoms.

If your angina persists despite this kind of aggressive medical therapy, then, by all means, a stent is something that should be strongly considered. But keep in mind that a stent only treats one particular plaque and that most people with CAD have several plaques. Furthermore, while most of these plaques are considered "insignificant" by traditional measures (since they are not producing many blockages in the artery), it now appears that the majority of cases of ACS occur when one of these "insignificant" plaques suddenly ruptures.

What this means is that, whether or not you end up getting a stent for your stable CAD, you still will need aggressive medical therapy to prevent the rupture of one of those "other" plaques, the "insignificant" ones, the ones for which too many cardiologists may express little or no interest.

Summary

If you are told you need a stent, you can quickly determine how urgently you need one, if at all, by asking three simple questions. These questions are so easy for your healthcare provider to answer—generally with a simple yes or no—that there will be no excuse for his/her failing to discuss them with you.

But, if it turns out that you have stable CAD and therefore a stent is at least not an emergency, you are owed a full discussion about all your treatment options before you are pressured into a stent.