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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
Anticoagulants such as Coumadin and lovenox don’t affect the platelets sufficiently, so they don’t prevent arterial thrombosis sufficiently.
Less invasive forms of bypass surgery have been developed, including off-pump bypass, and minimally invasive direct coronary artery bypass surgery (MIDCAB), but so far results have been inferior to standard bypass surgery. A cardiologist, of course, would say that the ultimate minimally invasive bypass procedure is the stent.
One huge problem cardiac surgeons have is that the patient flow is controlled by the cardiologists. They only see patients the cardiologists are unwilling to stent — the difficult cases with multiple blockages or blockages in very bad places.
Thanks DrRich,
Very informative and even if I do not need it right now, it is probably coming soon so I keep it handy.
So nice of you to share this high value information in a very digestible form. Great Ricochet value!
Very glad you’re doing well. Sounds like a stent was absolutely the right thing to do in your circumstance.
Figuring out how incredibly complex human physiology and new drugs fit together (or if they do) is not a challenge we have achieved yet.
Dual anti platelet therapy (DAPT) is the standard. I have used Plavix as shorthand here because most people have heard of it.
You bring up one of the problems with the drug abuse epidemic we don’t hear about enough. We hear about nasty people crossing the border, and overdose deaths, but not enough about the severe, chronic, expensive (and often futile) healthcare issues drug abusers often acquire.
In this regard I have two comments:
1) Wait, what?! In their allotted 7.5 minutes per patient encounter, doctors don’t even have enough time to communicate with their patients, let alone with their patients’ other doctors (note the plural).
2) Wait, what?! I thought the Obama-mandated EHR systems would automatically cure the lack of communication in the healthcare system. What gives?
Thanks. I write about heart disease as a paying gig at Verywell.com. I like to post here about medical stuff sometimes because I can have a little more fun with how I say things (to the point of using sarcasm occasionally, since we’re among friends), and I enjoy the interaction in the comments.
Regarding the picture appearing with this article:
1) Either that’s a really big stent, or the doctor has really small hands.
2) Most doctors use sterile techique when they handle stents. Make sure yours does.
3) He’s going to want a balloon-tipped catheter.
Awesome educational post, thanks! I’ve got a father with two stents and given the history of heart disease among men in my family, will probably be making these choices for myself someday. It’s great to have a primer at hand that’s in plain English.
They also may be functioning within the limits of American medicine. If you have only a 20 or 15 minute appointment time, to open up a discussion of alternatives to the preferred therapy can be more than impractical.
My own cardiologist has rigid 30 minute appointments. We have never failed to use all the allotted time, and I am doing well with no issues. I can only feel for those patients with complex issues and complications.
Do you blame them?
What mechanism stops bleeding in the bladder, in the prostate? Only platelets. Compromise those and a simple cysto or turp can bleed forever.
This post hits close to home.
A little more than two years ago, my wife suffered and survived a heart attack, thanks to a capable cardiologist and two stents. He described her condition as “complicated.” She inherited aggressive coronary artery disease from her father (dead at age 44) and her father’s father (dead at age 42). They were both life-long smokers. My wife had never smoked and that is probably the reason she made it to age 60 before the attack happened.
(Later, her cardiologist told us that he and his colleagues had never seen arteries so completely blocked in an otherwise healthy 60 year-old who wasn’t a chain smoker.)
The stent could only fix one artery. The other two were also blocked, and so she was treated for a year with aggressive meds (Plavix among them). Thirteen months later, she had open heart surgery, bypassing both the stent and one of the other arteries. The third artery was apparently so fragile it could not be bypassed.
We are a year out now from the bypass surgery. She continues to take clopidogrel (Plavix) at her cardiologist’s insistence. He continues to describe her condition as “complicated,” which tells me I am fortunate to still have her with me.
I had a stent inserted in Aug of 2015, on Plavix ever since , this seems to be saying I can never get off and that the risk of stroke will keep growing, am I reading it right?
Thank you – I forwarded to her. She had all those – all came back ok – not sure if she had an echo.
If hydrophobics can work for ketchup bottles, why not stents?
Not quite. The “optimal” duration of Plavix is something that has to be carefully judged for each individual, balancing estimated risks of discontinuing it vs. continuing it at various time intervals. You will need to work with your doctor to make a reasonable judgment on this.
The main point of this post is that placing a stent necessarily creates this ongoing medical issue. It’s something that needs to be taken into account before stents are used.
Work is being done with polymer-coated stents that are supposed to do something like this. We’ll have to wait and see how they finally work out — and, of course, THEIR unintended consequences.
I wish you both the best – I’ve seen people like your wife do well for many years.
Again, I agree, however they can’t just ignore the fact the patient is taking these meds for a reason and just ask them to stop them without incurring other risks.
This is a classic conundrum- if you want better coordination, you must countenance some risk to privacy, and deal with software standardization issue. Competing software companies don’t like standardization unless some higher power directs that their system become the standard, so we get fragmented uncommunicative systems all over. Ultralibertarians are rigidly opposed to accessing data (look at all the resistance out there to use of Limited Data Sets- a statutorily defined term, acronym easily confusion with Mitt’s religion- for research) needed to, you know, actually coordinate across specialties. I well remember the screams in 1993 when Al Gore suggested that personal medical records could be electronically stored on health insurance cards, a pretty sound idea for those terrified of The Cloud.
If we are going to have a a decentralized free market in health care, we need to set the parameters via regulation, which means federal. Medical records need to be in a common format, and easily accessed via SSN or something similar- whether the data are in The Cloud, an implanted memory chip (too 1984 for me), or something like a secure memory chip as part of a health card or national ID or whatever. If we choose not to do that, we have no cause to complain if our care is not coordinated and accounting for all the possibilities and interactions.
I agree with this. I too am in favor of EHRs, at least in concept. My problem with EHRs is not that they threaten to violate privacy — I believe this can be managed somehow, just as our on-line financial data is managed to most of our satisfactions. Instead, I object to the structure of the mandated EHRs in use today, which are designed primarily for the convenience of bureaucrats and forensic accountants (e,g, info on billing, tracking compliance, etc.). Any clinically-based processes in such EHRs have been glommed on later, as an afterthought. Consequently most EHRs hinder any real communication among caregivers, and may make it more difficult figure out what’s going on with the patient than it was with paper records. But the overseers like them just fine.
The problem with electronic records is that errors spread like viruses.
This story is funny only because it had a happy ending. My sister had a hip replacement surgery. She had had a couple of other medical issues resolved at the same hospital, and she has been in the care of the same primary care doctor for twenty years. The doctor’s records are shared with the hospital. Sounds great, but . . .
The surgeon was about to operate when he asked my sister about any allergies to antibiotics she had. She said she had an allergy to penicillin. He said, “But it says here [the computer screen] you are not allergic to penicillin. Why does it say that?” My sister replied, “I have no idea.” He was upset and stalled the surgery until he and the staff got to the bottom of the error.
In my own caregiving role with my kids, my husband, and my mom, I’ve seen many errors get enshrined in the computer records.
I don’t mind the electronic records. I know they save lives because of the speed with which they can be accessed. I only wish I could emblazon across every computer screen: “Check and double check. Don’t believe everything you read here.” :)
How did he get to the bottom of the error? One of the problems with computer records, as opposed to handwritten records, is that it’s often harder to track such things.
It doesn’t necessarily have to be that way, and database systems can be designed to track every datum and every change as to where it came from, by whom, and when, and to be able to see the change/transaction history. But that’s a tall order. Maybe modern medical systems do that. I’ve never worked with them.
I did notice my old primary physician struggling to work with the technology, even though in his new clinic (he no longer had an independent practice) there was an IT person to help him every step of the way. That was the last time I saw him; he left the practice of medicine at way too young an age (for which I blame ObamaCare) and I was stuck with finding a new primary physician. When I finally found one, in a big new hospital clinic, he was not interested in having my old records.
It’s usually not a problem to add new conditions to an EMR, such as a “new” allergy. The problem comes when you try to expunge an incorrect diagnosis from the record. It’s like (as some famous people have recently learned) trying to delete an email — the darned thing just keeps reappearing when it’s least convenient.