Angioplasty Sugery and After Stent Restenosis: Not Good News

Interventional cardiology has made lifestyle changes obsolete. Angioplasty surgery can open clogged vessels and put a stent in. But what about life after stent?

So your cardiologist has told you that you need to have a procedure done. They think the blood vessels going into your heart are blocked, and they want to slice you open near the groin, stick a probe up to your heart and check things out.

If they find a blockage, they’re going to open up the vessel and prop it up with a stent to keep it open.  Here’s where the big decision comes in:  Bare metal stent (BMS) or drug-eluting stent (DES)??

Let’s cover the choices.

Worst scenario that everyone wants to avoid is the full blown, chest cracking coronary artery bypass graft (CABG).  This is the end of the line as far as cardiac procedures (not counting death, which, arguably, is NOT a cardiac procedure….).

When percutaneous procedures began (this is the catheter that is inserted near the groin), they were initially done with just a balloon. The blocked artery was blown up and left alone. The problem was with restenosis, the term describing the re-closure of the artery. This was very common (upwards of 90% of cases) and sometimes let to emergency CABG.

Someone then came up with the idea of propping open the balloon-expanded artery with a piece of bare metal, essentially creating a tunnel. Working better than the balloon alone, but the restenosis rate was still a problem.

THEN, someone thought of coating the stent in an immunosuppresive drug (initially Sirolimus) to kill off the cells trying to grow back into the stent.

At this point, there was much argument about whether the bare metal stents or the drug eluting stents had better outcomes. The research was pointing towards DES being a better long term option. (Research, however, has shown that levels of inflammation are a determining factor here)

So, back to the decision you need to make before your groin region gets sliced and a tube inserted remotely into your vital organ…

Bare metal stent or drug eluting.  What if it REALLY doesn’t matter?

Sure, the short term outcomes seem to favor DES. But who wants to live only another year or two?

This particular study looked at longer, more realistic timeframes.

They also looked at the characteristics of the plaque forming inside of the stent. Lipid containing plaques are more likely to rupture, throwing off a clot and triggering a heart attack.  Not good.

Here’s what they found:

  1. 138 stents were looked at.
  2. In the early phase, under 9 months, the DES had much more fatty plaquing.
  3. In the intermediate phase, between 9 and 48 months the DES still had much fattier plaques.
  4. In the delayed phase, after 48 months the plaquing had evened out, and it was composed of the fattier, more dangerous, material.

So, in the long run, it doesn’t really matter what type of stent you or your cardiologist chooses, after 4 years the news is not good. While this study included a relatively small number of procedures, it seems to fit with what we know about the long term outcomes following this type of procedure. In non-emergent situations, we have known for years that percutaneous coronary intervention does not save lives over conservative care (which means drugs, which is a pretty poor standard to compare PCI to in the first place).

We have spent millions of research dollars to try to find out whether drug eluting or bare metal stents are the best option, and yet neither makes much of a difference in the long run. How much better could that money have been spent on educating the general public about something like refined carbohydrates?

If you happen to be in the population that has had a stent put in, never fear. The fact that this procedure, in someone who was not in the middle of an acute heart attack, has been shown in research studies to be worthless does not mean that there is nothing you can do.

Lifestyle changes will always prevail and have been shown again and again and again to lower the risk of cardiac events and death. Heck–even just adding in dark chocolate can greatly lower your odds of having a second heart attack.

So, if you have suffered a heart attack, what changes have you made to make sure it’s your last?

James Bogash
