Is coronary artery stenting needed for angina?


 IIs coronary artery stenting
needed for angina?

Before stenting of the coronary arteries patient should
be seen by a team of cardiologists who should
take decision about stenting

Lt. Gen. Mahmud Ahmad Akhtar
Former Surgeon General Army/DGMS (IS)
Prof Emeritus (Medicine and Therapeutics)

Coronary artery stenting is an expensive procedure-the cost of stents and in Pakistan the procedure fee is very high and there could be hazards also. Procedure is used on a very large scale, quite often misused. For the treatment of heart attacks, its use has been justified on evidence-based studies, for narrowing of arteries causing angina (chest pain) firm evidence has been lacking.

Lt. Gen. (R.) Mahmud Ahmad Akhtar

In 2007, a large study led by Dr. Borden without an untreated control group found stents did not prevent heart attacks or deaths. The explanations the researcher said was that atherosclerosis is a diffuse disease. A few arteries may be blocked today and then re-opened with stents. But tomorrow a blockage might occur in another artery and cause a heart attack. For many cardiologist relieving angina was a different proposition. The study published in the prestigious London medical journal ‘LANCET’ on Nov 2 issue raised question about whether stents should be used so often if at all to treat angina.

For the study, Dr. Justin E. DAVES a cardiologist at the renowned Imperial College London and the colleagues enrolled two hundred patients with a profoundly blocked coronary artery and chest pain, severe enough to limit physical activity. All were treated for six weeks with drugs like aspirin, a statin and a beta-blocker, and nitrates. Then the subject had a procedure, a real or a fake insertion of a stent. This is one of the rare studies in cardiology in which a sham procedure was given to controls who were then compared to patients receiving the actual treatment. It was a double blind study neither the patients nor the doctors knew which patient received stents and which did not. The blood flow through the stented blocked arteries was greatly improved when the researchers tested the patients six weeks later, both groups said that they had less chest pain and they did better than before on tread-mill test.

The researchers found no difference between the two groups. Those who got sham treatment did as well as those who got stents. Following the procedure, both groups of patients took anti-thrombosis drugs.

In the USA Dr. Nallomoth read the new study and co-incidentally also had a patient Jim Stevens 54 year old, a lawyer scheduled to receive a stent that day. Mr. Stevens had a blocked artery but the new report based on a solid scientific line gave Dr. Nallomoth second thoughts “I took him off the table” he said. In my medical practice, I had many patients who did not get stenting for different reasons did well on medicines – anti-platelets, beta-blockers, ACE1/A2A, STATINS, of course that is a clinical impression. One patient is 89 year old a prominent Pharmacist who was advised a By-pass surgery at a cardiac institute by a cardiologist and a cardiac surgeon and stenting at another institute. Another cardiologist opined neither to have surgery and no stenting. He continued on drugs for the last three years without having any untoward event. He comfortably walks tree kilometers daily. Of course, it is not a valid scientific study.

In Pakistan, the procedure of coronary stenting is done on a large scale without any over-sight. Recently there was a huge scandal about the quality and pricing of stents. Many stent traders in collaboration with many doctors were using poor quality un-approved stents at exorbitant prices.

Many doctors use stents on gullible people unethically and charge enormous amount. There are no laid down guide-lines. I know many patients who had been cheated. A patient was charged over a million rupees by a cardiologist in a leading cardiac institute claiming to have inserted seven stents when only one was found to be inserted at the hospital when he went for his checkup. A large number of patients suffer.

Many earlier studies had cast doubt on the feasibility of using stents in patients suffering from Angina due to narrowing of coronary arteries. The present study done at the prestigious Imperial College of London by eminent cardiologist a double blind one with controlled patients having sham stents deserves full consideration for many guide-lines.

The “Pakistan Cardiac Society” should study the report of the London Imperial College trial and issue guide-lines for the doctors to follow. The Ministry of Health Govt. of Pakistan should also take initiative. This is in the wide interest of patients many of whom are illiterate or semiliterate are exploited with no fault of theirs. I suggest that patients undergoing stenting of the coronary arteries should be seen by a group of consultant cardiologists who should take decision about stenting in a meeting, based on guide-lines. This is done by many institutes in Europe.

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