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Something Cardiologists Don’t Like Talking About
Doctor holding a stent.
I am presenting this bit of secret cardiology as a courtesy to my friends here on Ricochet.
If your cardiologist wants to insert a stent for a blockage in your coronary artery, he/she is likely to tell you something like this: “Once we get the stent in place, you will need to be on Plavix to reduce your cardiac risk going forward. Plavix helps to prevent a clot from forming on the stent. Since Plavix can cause an increased risk of bleeding, you will need to be especially careful about cutting yourself or getting bumps or bruises. Plavix also makes surgery more difficult, so you will have to try to avoid elective surgery while you’re on it. If any other doctor tells you to stop the Plavix for any reason, don’t do so until you talk to me. You will need to be on Plavix for at least 12 months, and maybe longer.”
If you get such a speech, you are not being lied to. But you are getting a message that is at least somewhat dampened. In fact, a reasonable response to the talk your doctor ought to be giving you might be, “Holy crap! Doc, isn’t there something we can do besides a stent?” If this is not your response, your doctor may not be providing you the full flavor of the problem.
(I am arbitrarily using “Plavix” here to represent a family of powerful anti-platelet drugs. The other available drugs in this family, sometimes used after stent placement, are Effient and Brilinta.)
Why Stents Are Useful
A stent is a tiny arrangement of (typically) metal struts that is inserted by means of a catheter passed across a coronary artery plaque that is causing a blockage. The stent is expanded by filling a balloon, which smashes (not the technical term) the plaque, and opens the artery. The stent then provides a permanent support structure to keep the artery open.
In the early days (late 1970s to 1980s), angioplasty (the balloon inflation part of the procedure) was used by itself. Unfortunately, in almost 50% of cases, restenosis (recurrence of the blockage) would occur within a year or so. Stents were designed to minimize this gradual restenosis. With the earliest stents, the incidence of restenosis was reduced to about 10%. With the later introduction of stents coated with drugs that prevent the growth of cells (drug-eluting stents, or DES), the risk of restenosis was lowered to less than 5%. And with current generation DES, restenosis now apparently occurs less than 1-2% of the time.
So, modern stents allow the successful long-term treatment of localized coronary artery blockages, without requiring cardiac bypass surgery. Cardiologists regard stents as perhaps the greatest advance in treating coronary artery disease in the past 50 years, and accordingly, inserting stents has become the bread and butter of the cardiology profession.
The Problem With Stents – Thrombosis
Early thrombosis — the acute formation of a blood clot in days or weeks after the procedure — was recognized immediately as a problem with both angioplasty and stents. From the beginning, patients receiving these therapies were given Plavix for variable periods of time (usually 1 to 6 months) to prevent this early thrombosis. Plavix worked very well in this regard.
However, within a few years it was recognized that patients receiving stents had a small, residual risk of acute thrombosis that persisted past the first 6 months. While the incidence of the problem was low (1 – 2% after a year or two), the event itself is catastrophic. Stent thrombosis causes sudden, complete blockage of the artery. At a minimum, the heart muscle supplied by the artery dies (which is what is meant by a “heart attack”), and often, the result of stent thrombosis is the sudden death of the patient. If acute stent thrombosis occurs, it is not likely that treatment will be available quickly enough to prevent a large heart attack or death. So stent thrombosis is a very, very big deal.
Because of the relatively small, but very devastating, ongoing risk of stent thrombosis, treatment with Plavix is now routinely continued for at least 6-12 months after stent placement. In fact, current evidence suggests that a small but measurable risk of stent thrombosis persists well beyond 12 months, and that cardiac outcomes are significantly improved by continuing Plavix for up to 30 months after stent placement, or even longer.
The Problem With Plavix
Prolonged treatment with Plavix (and similar drugs) after a stent is problematic. The risk of life-threatening bleeding in people taking Plavix occurs as a linear function — that is, the longer you’re on it, the greater the risk of major bleeding episodes. (“Major bleeding” includes any fatal bleeding, intracranial bleeding (stroke), or bleeding that causes cardiovascular collapse, or requires transfusion or surgery.) In fact, from current evidence it looks like, while Plavix continues to significantly reduce the risk of stent thrombosis (and improves cardiac outcomes) well beyond 12 months, overall mortality may actually become higher in people who remain on Plavix therapy for very long periods of time.
On the other hand, data suggests pretty strongly that stopping Plavix for any reason acutely increases the risk of stent thrombosis, likely for a period of several weeks. This makes cardiologists very reluctant to allow their stent patients to come off Plavix even temporarily, say, for a surgical procedure.
Speaking of which, surgeons are very reluctant to operate on people taking Plavix, more reluctant than they are to operate on people taking other kinds of blood thinners such as Coumadin. People on Coumadin bleed a lot from tiny veins and arteries, and it takes substantial effort for surgeons to cauterize all the little “bleeders” they encounter when they make an incision. But with Plavix, the bleeding occurs not only from tiny blood vessels, but also from capillaries — so when you make an incision there is constant oozing from all the tissues everywhere, and the bleeding is far more difficult to control.
Because so many people with heart disease are taking Plavix these days, in recent years many surgeons have learned (very reluctantly) to more-or-less cope with the bleeding they encounter. For this reason the shouting matches between surgeons (who insisted on stopping Plavix for any operation) and cardiologists (who insist on continuing the drug no matter what) have become a little less vociferous. Most surgeons are still quite reluctant to operate on these people, but many will do so under duress, and some have even made a niche for themselves by doing so. But surgery still remains more difficult, and sometimes much riskier, for a patient on Plavix. So for anyone on Plavix who needs surgery, having to find a surgeon comfortable enough to operate on them adds another layer of complexity to their already complicated medical issues.
Furthermore, it greatly behooves patients on Plavix to avoid things like car accidents or head trauma, because being on this drug can transform what might have been merely a nasty episode into a deadly one.
The Bottom Line
Stents are a marvel of modern engineering, and are continuing to get better. But for most cardiologists the enthusiasm about stents has been tempered by the issue of late stent thrombosis, and the problems inherent in taking Plavix for a long time. As things currently stand, when you get a stent you may be ameliorating one medical problem, but you are certainly agreeing to accept a new and long-lasting medical issue, one whose optimal therapy (beyond the first 12 months at least) is still not fully understood.
Under certain circumstances a stent can clearly be a life-saving or disability-preventing treatment. For patients having an acute heart attack or unstable angina, stents often appreciably improve both short-term and long-term outcomes. In these patients, given the alternative therapies available, receiving a stent is almost always the better part of the benefit/risk calculation.
But for people who have stable coronary artery disease — those who have “significant blockages” without discernible symptoms, or who have stable angina (angina that occurs in a predictable fashion with exertion or psychological stress) — there is little or no proof that stents improve cardiac outcomes compared to aggressive drug therapy. (There are exceptions to this general rule for blockages that occur in specific locations in the coronary arteries.) Most people in this category should strongly consider medical therapy to reduce their cardiac risk and control their symptoms, instead of a stent. If they do decide to get a stent, it ought to be under the clear knowledge that it is unlikely the stent will measurably reduce their risk of a heart attack or death compared to aggressive medical therapy alone. Rather, the stent is being used to reduce their symptoms of angina. They should think about the benefits of doing so versus the risks of long-term Plavix.
Also, there’s always the option of bypass surgery instead of a stent, though I believe the Cardiologist’s Secret Pledge requires me not to recommend it. (I no longer practice, and it’s been a few decades since I looked at it.)
Cardiologists who fail to paint the full picture regarding stents are, for the most part, not being evil. Rather, they are simply engaged in the universal human endeavor of rationalizing away the things that are simply too inconvenient to be true.
Published in General
I’ve seen a push away from stents of course too. Plavix is a scary drug for any potential bleeder but what are you going to do?
Effient may have better outcomes cardiac wise but the bleeding remains the scary part.
Obviously byapssing the bypass with lifestyle is preferable but I still refer for those occasionally.
Thanks, Doc, you just made me smarter. There’s no history of heart problems in either my or my wife’s families, but this goes into the permanent bookmark file just in case.
This post has a lot of heart.
But seriously, have they tried coating the stents with a hydrophobic agent to prevent build-up?
Oh my daily battle! Stent forms! I work as a nurse in preop and some surgeons just don’t get the “big deal” about why we need the cardiologist’s approval for the patient to stop their anticoags. We beg them (surgeons) to make sure they have consulted with their cardiologist about their meds and provide us with written documentation so we know it is ok. I know what some of you are thinking, shouldn’t the patient be responsible? Well, that Jeannie has been out of the bottle for a while. Good luck putting her back in. Some docs have at least come around to being ok with the patient staying on their aspirin for surgery. All except the urologists. They are scared to death of anything that might cause bleeding.
Ok. Off my soap box.
antibiotics
They have tried coating stents with all manner of drugs, in the lab, in animals, and (when things look promising) in patients. The improvements achieved so far are as I have described.
Recently, bioresorbable stents are being developed, in which the stent disappears altogether within several months (when the support they provide is judged no longer necessary). All players have been betting that this solution will at last solve the late thrombosis issue. Alas, with the first generation bioresorbable stent tested, thrombosis still looks like a problem with relatively early evidence. Everyone hopes that later evidence, or next-gen bioresorbables, will give better results.
I have no doubt that this problem will indeed be solved with technological breakthroughs sooner or later. Unless we decide to disallow companies from charging big bucks when they make such breakthroughs, major research efforts will continue.
Thanks for that post. That’s the sort of information that I wish I could get from doctors, but usually they don’t want to explain much these days.
Fortunately, at the moment (age in the high 60s) I still enjoy answering the question of, “What medications are you taking,” with “None.” Or when they say, “Bring all your medications to your first appointment,” I say, “That’s easy. There aren’t any.”
I dread the day when that will change, because every medication I’ve ever taken has had undesirable side effects.
Back when I was a PhD student in a Zoology department (I didn’t stay in the program long) doctors often gave me better information, as if I understood everything they were telling me, even though my primary interest was invertebrates. But years later, when they found out where I worked, it seems that my presence instead reminded a few of them that they hadn’t followed their first love (Forestry, Ecology, whatever) and had switched to medicine, where the money was. I’m not sure that was good. There is an orthopedic surgeon who always preferred to talk about his days as an ecology student in our department rather than my quadriceps tendon, or he’d regale everyone around with the story of how high the blood spurted when he stuck his scalpel in my knee. The story got better and the blood spurted higher each time he told it.
When I said that many surgeons have grudgingly begun operating on patients taking these drugs, I was NOT referring to urologists. Prostate surgery in patients taking Plavix has been and remains a disaster. Urologists are right to be recalcitrant here.
My father’s cardiologist recommended a stent c. 2005. When I discussed the procedure with the cardiologist, he presented it as a precautionary measure; it sounded optional to me. We decided to go ahead anyway since he made it sound routine. Flash forward to 2015. My father is still taking Plavix. Finally, his primary care physician takes him off Plavix after roughly a decade. I had assumed it was necessary to continue taking the drug indefinitely because of the stent.
This anecdote would seem to reinforce DrRich’s point.
If you think orthopedists have weird fish stories, spend a little time with a urologist.
I’m with you. They always seem so surprised.
I can understand their reluctance. If we can just get them to understand it needs to be addressed in some way, I’d be happy.
My favorite types of patients, BORING!
My sister – age 58 is on Plavix because she had an episode at work where she could not see the screen well – like staring at the sun – she was taken to hospital and had every kind of test, cat scan and all came back ok. Kept overnight for observation then released. A physician’s Asst has her on it for a year as a precautionary along with low dose aspirin. She started bruising – I told her to stop aspirin – is this extreme for getting a clean bill of health? She has never had a problem before and is not on any other meds.
There are several reasons to prescribe Plavix. Maybe one of them applies to your sister. But Plavix is a serious drug, and she is owed a clear explanation of why Plavix is necessary. And if she can’t get one she needs to see another doctor.
I think a neurologist is in order here. Show me the echocardiogram w bubble study, carotid scan, MRI/MRA of head before the plavix.
Please stay on it!
The Gastro-Surgeon for my Dad, age 89, (to remove two polyps from colon), did not consult father’s cardiologist regarding meds (including blood thinners), or father’s overall heart condition. Neither did my family living in same city talk to his primary care or cardiologist because their thought process was (and remains) “if it’s important the G-Surgeon will tell us”, we don’t need to be bugging him with questions, getting second opinions, getting written clearance letters from the Cardiologist, etc.
Result? Stroke (cluster clot) and another gastro surgery the next day due to serious internal bleeding.
Here is something else I think people need to know, since my father’s surgery was considered “elective” by the hospital he was not assigned a Hospitalist. Thus the only Doctor overseeing my father’s care despite his diabetes, heart disease (he has a pacemaker), and other issues was a Gastro-Surgeon who did not call-in or consult with any other doctors.
Wanting a Hospitalist assigned to oversee my care while in the Hospital is the reason I entered the hospital via the Emergency Room when I was scheduled for open heart surgery (told them I was having palpitations, etc.) . I wanted to be a patient of the Hospital, not just a patient of the Vascular Surgeon (a miracle worker in my case).
BTW, I too was put on meds after surgery — I was off all at 4 months.
@temptime, our anesthesiologists have our backs about this stuff. Most of our surgeons are good about it. There are a few outliers.
Now, I do love our hospitalists, but I miss the days when a patient’s regular physician could follow them in the hospital.
This needs more likes so it goes main feed. Life saving info here, not only in OP, but in the comments.
Thanks for this informative post Dr Rich. As far as I know, I don’t have any heart issues, but I’m saving this for reference.
Perhaps more frightening, I’ve had a lot of patients lately who came off it for surgery and ended up with a stroke or a PE.
Thank you for this post, and your writing style. It was easy to read, clear to understand, and made an impression.
I’ve already spent way too much time with urologists, if you know what I mean. I was anesthetized for some of it; even so, I have my own urologist fish stories.
According to my contract you can’t make me do this… So, I demand you bring in a stent double.
I had a stent put in for unstable angina in 2009 (age 49). Major descending artery 90%+ blocked. I was on Plavix for 18 months or so with the only issue being conflict with my proton pump inhibitor for GERD. They stopped some version of PTPI almost until I could not eat and put me on Nexium.
I am alive because of the stent and no relapse (yes, that’s the wrong word). Both my mother and my father have (or had in the later case) heart disease. So I am in the top of the risk category.
I am happy modern medicine and my doctor saved my life.
I do wonder if we really know how all these systems fit together. That is all these drugs and all our internal complexity.
Two questions that occurred to me:
I know that balancing the dose for warfarin and friends is a massive pain, but I’ve heard good things about Lovenox (enoxeparin IIRC?). Any way to use that as opposed to Plavix and friends? In particular, is there a way to use a locally active anticoagulant in the stent?
Also, have there been any advances toward less invasive / traumatic bypass surgery?
@DrRich, great post, and timely. One of my dialysis patients had a distal RCA drug-eluting stent placed with no other CAD. To be clear, he will need to be on dual anti-platelet therapy (Plavix AND aspirin) for at least a year. The problem? He abuses cocaine, has uncontrolled hypertension and has two large bore needles placed in a high pressure fistula three times a week. This is a disaster in waiting. He did not ask for my opinion before proceeding. This gets to one of the biggest problems in modern medicine:the appalling lack of communication and the continuing fragmentation of medical care that deserves its own post.