What do physicians and stent companies have to say for themselves, given that they are promoting expensive, risky procedures with no benefit?
Angioplasty Heart Stent Risks vs. Benefits
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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
Angioplasty and stent placement continue to be frequently performed for patients with non-emergency coronary artery disease, despite clear evidence that it provides minimal benefit. For example, it does not prevent heart attacks or death, yet as many as 9 out of 10 patients mistakenly believed that the procedure would reduce their chances of having a heart attack. But at the same time, the cardiologists weren’t stupid. Those who referred them for the stent and those who performed the procedure didn’t believe that. Okay, then why were they doing it? Focus groups of cardiologists have documented a chasm between knowledge and behavior. While aware of the evidence to the contrary, they recommend and perform PCI (angioplasty and stents), because they somehow believe that it helps in some ill-defined way. “[P]hysicians tended to justify a non-evidence-based approach (“I know the data shows there is no benefit, but”) by focusing on [how easy it is to do the procedure] and belief that an open artery was better” even if it didn’t actually affect outcomes, all the while minimizing the risks. I mean the procedure only kills 1 in 150. So, here some are blaming the patients for not listening, but maybe it’s the physicians who are the ones ignoring the evidence.
Or maybe physicians have too poor a grasp of the relevant statistics to adequately inform the patient? Regardless, what we’ve got here is a failure to communicate. So, tools have been developed. For example, a sample informed consent document that lays out the potential benefits and risks, even laying out how many procedures your doctors have done and your out-of-pocket costs. Note there are a lot of blanks to be filled in, though. What are some concrete numbers?
The Mayo Clinic came up with some prototype decision-making tools. In terms of benefits, will having a stent placed in my heart prevent heart attacks or death? No, stents will not lower the risk of heart attack or death, but a week later those getting stents report they feel better at least, though a year later even the symptomatic-relief benefit appears to disappear. Okay, so there appeared to be this temporary-relief-in-chest-pain benefit. What about the risks?
During the stent procedure, out of 100 people, two will have bleeding or damage to a blood vessel, and one will have a tad more serious complication such as heart attack, stroke, or death. And then, after that, during the first year after the stent, three will have a bleeding event because of the blood thinners you have to take because you have this foreign material in your heart, but that doesn’t always work, and so two will have their stent clog off leading to a heart attack.
What does the world’s #1 stent manufacturer have to say for itself? They acknowledge the evidence shows stents don’t make people live longer, but living longer is overrated. Look, if all we cared about was living longer, entire disciplines of medicine would disappear. Why go to the dentist? Of course, the difference is that 80 percent of people don’t believe that getting a cavity filled is going to save their life, like they mistakenly do for stents, and there isn’t a one in a hundred chance you won’t make it out of the dentist chair.
The stent companies actively misinform with ads like this. “Open your heart and your life.” “Life wide open.” “Freedom begins here.” Their TV ad mentioned a few side effects. Turns out they missed a few, but more importantly, they’re giving the false impression that stents are more than just expensive, risky band aids for temporary symptom relief. But what’s wrong with symptom relief? Look at those smiling faces. Even if the benefits are only symptomatic and don’t last long, if people think that outweighs the risk, what’s the problem?
What if I told you that even the symptom relief may just be an elaborate placebo effect, and you could get the same relief from a fake surgery; so, there really weren’t any benefits at all? We’ll see what the science says next.
Please consider volunteering to help out on the site.
- Rothberg MB. PCI for stable angina: a missed opportunity for shared decision-making. Cleve Clin J Med. 2018;85(2):105-21.
- Rothberg MB, Sivalingam SK, Ashraf J, et al. Patients' and cardiologists' perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med. 2010;153(5):307-13.
- Waters DD. Papering over the cracks: meta-analysis to define the role of percutaneous coronary intervention in patients with stable angina. Can J Cardiol. 2013;29(4):411-4.
- Lin GA, Dudley RA, Redberg RF. Why physicians favor use of percutaneous coronary intervention to medical therapy: a focus group study. J Gen Intern Med. 2008;23(9):1458-63.
- Liao L. Benefits of coronary revascularization: a failure to communicate. Am Heart J. 2007;154(4):613-4.
- Krumholz HM. Informed consent to promote patient-centered care. JAMA. 2010;303(12):1190-1.
- Coylewright M, Shepel K, Leblanc A, et al. Shared decision making in patients with stable coronary artery disease: PCI choice. PLoS One. 2012;7(11):e49827.
- Coylewright M, O'Neill ES, Dick S, Grande SW. PCI Choice: cardiovascular clinicians' perceptions of shared decision making in stable coronary artery disease. Patient Educ Couns. 2017;100(6):1136-43.
- Meier B, Nietlispach F. Fallacies of Evidence-Based Medicine in Cardiovascular Medicine. Am J Cardiol. 2019;123(4):690-4.
- Cordis.
- Cordis.
- Cordis.
- Boden WE, Diamond GA. DTCA for PTCA—crossing the line in consumer health education?. N Engl J Med. 2008;358(21):2197-200.
- Hamblin J. Placebo effect of the heart. The Atlantic. November 8, 2017.
- Wallis C. How Fake Surgery Exposes Useless Treatments. Scientific American. February 1, 2018.
Video production by Glass Entertainment
Motion graphics by Avocado Video
Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
Angioplasty and stent placement continue to be frequently performed for patients with non-emergency coronary artery disease, despite clear evidence that it provides minimal benefit. For example, it does not prevent heart attacks or death, yet as many as 9 out of 10 patients mistakenly believed that the procedure would reduce their chances of having a heart attack. But at the same time, the cardiologists weren’t stupid. Those who referred them for the stent and those who performed the procedure didn’t believe that. Okay, then why were they doing it? Focus groups of cardiologists have documented a chasm between knowledge and behavior. While aware of the evidence to the contrary, they recommend and perform PCI (angioplasty and stents), because they somehow believe that it helps in some ill-defined way. “[P]hysicians tended to justify a non-evidence-based approach (“I know the data shows there is no benefit, but”) by focusing on [how easy it is to do the procedure] and belief that an open artery was better” even if it didn’t actually affect outcomes, all the while minimizing the risks. I mean the procedure only kills 1 in 150. So, here some are blaming the patients for not listening, but maybe it’s the physicians who are the ones ignoring the evidence.
Or maybe physicians have too poor a grasp of the relevant statistics to adequately inform the patient? Regardless, what we’ve got here is a failure to communicate. So, tools have been developed. For example, a sample informed consent document that lays out the potential benefits and risks, even laying out how many procedures your doctors have done and your out-of-pocket costs. Note there are a lot of blanks to be filled in, though. What are some concrete numbers?
The Mayo Clinic came up with some prototype decision-making tools. In terms of benefits, will having a stent placed in my heart prevent heart attacks or death? No, stents will not lower the risk of heart attack or death, but a week later those getting stents report they feel better at least, though a year later even the symptomatic-relief benefit appears to disappear. Okay, so there appeared to be this temporary-relief-in-chest-pain benefit. What about the risks?
During the stent procedure, out of 100 people, two will have bleeding or damage to a blood vessel, and one will have a tad more serious complication such as heart attack, stroke, or death. And then, after that, during the first year after the stent, three will have a bleeding event because of the blood thinners you have to take because you have this foreign material in your heart, but that doesn’t always work, and so two will have their stent clog off leading to a heart attack.
What does the world’s #1 stent manufacturer have to say for itself? They acknowledge the evidence shows stents don’t make people live longer, but living longer is overrated. Look, if all we cared about was living longer, entire disciplines of medicine would disappear. Why go to the dentist? Of course, the difference is that 80 percent of people don’t believe that getting a cavity filled is going to save their life, like they mistakenly do for stents, and there isn’t a one in a hundred chance you won’t make it out of the dentist chair.
The stent companies actively misinform with ads like this. “Open your heart and your life.” “Life wide open.” “Freedom begins here.” Their TV ad mentioned a few side effects. Turns out they missed a few, but more importantly, they’re giving the false impression that stents are more than just expensive, risky band aids for temporary symptom relief. But what’s wrong with symptom relief? Look at those smiling faces. Even if the benefits are only symptomatic and don’t last long, if people think that outweighs the risk, what’s the problem?
What if I told you that even the symptom relief may just be an elaborate placebo effect, and you could get the same relief from a fake surgery; so, there really weren’t any benefits at all? We’ll see what the science says next.
Please consider volunteering to help out on the site.
- Rothberg MB. PCI for stable angina: a missed opportunity for shared decision-making. Cleve Clin J Med. 2018;85(2):105-21.
- Rothberg MB, Sivalingam SK, Ashraf J, et al. Patients' and cardiologists' perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med. 2010;153(5):307-13.
- Waters DD. Papering over the cracks: meta-analysis to define the role of percutaneous coronary intervention in patients with stable angina. Can J Cardiol. 2013;29(4):411-4.
- Lin GA, Dudley RA, Redberg RF. Why physicians favor use of percutaneous coronary intervention to medical therapy: a focus group study. J Gen Intern Med. 2008;23(9):1458-63.
- Liao L. Benefits of coronary revascularization: a failure to communicate. Am Heart J. 2007;154(4):613-4.
- Krumholz HM. Informed consent to promote patient-centered care. JAMA. 2010;303(12):1190-1.
- Coylewright M, Shepel K, Leblanc A, et al. Shared decision making in patients with stable coronary artery disease: PCI choice. PLoS One. 2012;7(11):e49827.
- Coylewright M, O'Neill ES, Dick S, Grande SW. PCI Choice: cardiovascular clinicians' perceptions of shared decision making in stable coronary artery disease. Patient Educ Couns. 2017;100(6):1136-43.
- Meier B, Nietlispach F. Fallacies of Evidence-Based Medicine in Cardiovascular Medicine. Am J Cardiol. 2019;123(4):690-4.
- Cordis.
- Cordis.
- Cordis.
- Boden WE, Diamond GA. DTCA for PTCA—crossing the line in consumer health education?. N Engl J Med. 2008;358(21):2197-200.
- Hamblin J. Placebo effect of the heart. The Atlantic. November 8, 2017.
- Wallis C. How Fake Surgery Exposes Useless Treatments. Scientific American. February 1, 2018.
Video production by Glass Entertainment
Motion graphics by Avocado Video
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Title
Angioplasty Heart Stent Risks vs. Benefits
LicenseCreative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)
Content URLDoctor's Note
I know I spoiler-alerted the whole no-benefits thing, but you have to see it to believe it. There are three videos left in this seven-part series. Coming soon:
- Do Heart Stent Procedures Work for Angina Chest Pain?
- Why Are Stents Still Used If They Don’t Work?
- Heart Stents and Upcoding: How Cardiologists Game the System
If you missed the first three videos, see:
- Do Angioplasty Heart Stent Procedures Work?
- Why Angioplasty Heart Stents Don’t Work Better
- The Risks of Heart Stents
As I say over and over in this video series, during a heart attack, in an acute setting, angioplasty can be life-saving. As I reiterate, when I’m talking about stable CAD, I’m talking nonemergency situations. In an upcoming series I talk about pros and cons of statin drug therapy. Spoiler: If you have a history of heart disease or stroke, taking a statin is recommended. All of these videos, including the upcoming statin series, are available on a digital download of a webinar I did last year. You can find it here.
UPDATE: A new meta-analysis was just published last month and alas, there is still zero survival benefit to stent placement for stable coronary artery disease, but at least there were fewer heart attacks. Since this still didn’t translate into actually living any longer, the foundation of treatment remains medical and lifestyle management. Hat tip to Dr. Bitterman!
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