There are demonstrably no benefits to the hundreds of thousands of angioplasty and stent procedures performed outside of an emergency setting. They don’t prevent heart attacks, enable you to live longer, or even help with symptoms any more than placebo (fake) surgery.
Do Angioplasty Heart Stent Procedures Work?
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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.
The large national cardiology conferences may attract the majority of cardiologists in the entire country to one place. So, hey, if you’re going to have a heart attack, that would seem to be the place to do it. And indeed, that’s when the American Heart Association president had his, within hours of his presidential address. With so many of the nation’s top cardiologists at the conference, maybe that’s a bad time to go into cardiac arrest anywhere else, though. You don’t know, until you put it to the test.
To their surprise, they found substantially lower mortality among those going into cardiac failure or cardiac arrest during the big national cardiology meetings. Why is the death rate lower when most of the cardiologists are away? One potential explanation is that the intensity of care may be lower, suggesting the harms of such care may unexpectedly outweigh the benefits. Their results echo paradoxical findings documented during a labor strike by Israeli physicians, during which mortality rates evidently dramatically fell. And it wasn’t just one strike. This has been looked at multiple times, and in all reported cases, mortality either stayed the same or decreased. In four of the seven cases, mortality dropped as a result of the strike, and in three, there was no significant change.
The fact is that many current medical practices have been found to offer no benefit, and, in fact, potential harms. Even physicians themselves estimate that about one-fifth of medical care is unnecessary. A national summit was convened by the joint commission that accredits hospitals and the American Medical Association to identify areas of overuse—treatments that provide zero or negligible benefit—potentially exposing patients to the risk of harm for nothing. They called out five practices: for example, prescribing antibiotics for viral upper respiratory tract infections, spending a billion dollars prescribing drugs that don’t work (and if anything just make things worse). But another overused practice they identified was elective percutaneous coronary intervention––in other words, angioplasty and stents.
Just to get everyone on the same page before we dive in, coronary artery disease, the #1 killer of men and women, involves blockages in the blood vessels that supply the heart muscle itself. Low blood flow can lead to a type of chest pain called angina or, if severe enough, to a heart attack. Plant-based diets and lifestyle programs have been shown to reverse these blockages by treating the cause of why our arteries are clogging up in the first place. But, for those unable or unwilling to change their diets, there are drugs that can help, as well as more invasive treatments such as open-heart surgery to try to bypass the blockage, or percutaneous coronary intervention. That’s when doctors insert small balloons or metal tunnels, called stents, up through the large blood vessels typically in the groin, and thread them all the way up into the heart. That way, you can then get inside the blocked vessels, and try to open them up and prop them open. During a heart attack this can be lifesaving. But hundreds of thousands of these procedures are done every year for stable angina, meaning on a non-emergency basis, which can relieve symptoms but doesn’t actually reduce your risk of having or dying from a heart attack in the future.
However, not everyone knows that. They mistakenly think the procedure offers more than just symptom relief. That’s one of the reasons I’m doing this video series. As Harvard put it, stents are for pain, not protection. But then, unbelievably, it was discovered that stents may not even help with pain, as revealed in this double-blind, randomized controlled trial. Wait, you can blind people to the active treatment in drug trials by giving them a placebo sugar pill, but wouldn’t you kinda notice if you got surgery or not, whether or not they cut into your groin? Not if you got sham surgery—placebo surgery—where they cut into everyone, thread up the catheter, and at the last moment, randomly actually do or do not actually place the actual stent. And those who got the fake surgery did just as well as those who got the regular surgery. Wait, there are no benefits to angioplasty and stents outside of an emergency setting? Doesn’t prevent heart attacks, doesn’t enable you to live longer, and doesn’t even help with symptoms? And since the procedure carries risks—including death—maybe stents should be used only for people who are actively having heart attacks. But wait, so hundreds of thousands of people are getting these operations for nothing? How do the doctors justify it? Is it just greed? How do they get patients to sign up it? Do they just not tell them the truth? And wait, why doesn’t it work? After all, you are opening up a blocked artery. There are just so many questions, which we’ll start addressing next.
Please consider volunteering to help out on the site.
- Mano T, Yamamoto K. Report of the American College of Cardiology (ACC) Scientific Sessions 2016, Chicago. Circ J. 2016;80(6):1308-13.
- Redberg RF. Cardiac patient outcomes during national cardiology meetings. JAMA Intern Med. 2015;175(2):245.
- Seo Y. Report of the American Heart Association (AHA) Scientific Session 2017, Anaheim, California. Circ J. 2018;82(2):323-7.
- Jena AB, Prasad V, Goldman DP, Romley J. Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings. JAMA Intern Med. 2015;175(2):237-44.
- McCarthy M. Death rate is lower in high risk heart patients at US teaching hospitals during cardiology conferences. BMJ. 2014;349:g7858.
- Siegel-Itzkovich J. Doctors' strike in Israel may be good for health. BMJ. 2000;320(7249):1561.
- Cunningham SA, Mitchell K, Narayan KM, Yusuf S. Doctors' strikes and mortality: a review. Soc Sci Med. 2008;67(11):1784-8.
- Morgan DJ, Dhruva SS, Coon ER, Wright SM, Korenstein D. 2018 Update on Medical Overuse. JAMA Intern Med. 2019;179(2):240-6.
- Lyu H, Xu T, Brotman D, et al. Overtreatment in the United States. PLoS One. 2017;12(9):e0181970.
- Proceedings from the National Summit on Overuse. 24 September 2012. The Joint Commission. Physician Consortium for Performance Improvement.
- Esselstyn CB. A plant-based diet and coronary artery disease: a mandate for effective therapy. J Geriatr Cardiol. 2017;14(5):317-20.
- Summaries for patients. Patients' and cardiologists' beliefs about a common heart procedure. Ann Intern Med. 2010;153(5):I46.
- Rothberg MB, Scherer L, Kashef MA, et al. The effect of information presentation on beliefs about the benefits of elective percutaneous coronary intervention. JAMA Intern Med. 2014;174(10):1623-9.
- COURAGE to make choices. Harvard Heart Letter. June 2007.
- Kolata G. ‘Unbelievable’: Heart Stents Fail to Ease Chest Pain. The New York Times. November 2, 2017.
- Al-Lamee R, Thompson D, Dehbi HM, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet. 2018;391(10115):31-40.
- Brown DL, Redberg RF. Last nail in the coffin for PCI in stable angina?. Lancet. 2018;391(10115):3-4.
- Coey D. Physicians’ Financial Incentives and Treatment Choices in Heart Attack Management. Quant Econom. 2015;6(3):703-48.
- Goff SL, Mazor KM, Ting HH, Kleppel R, Rothberg MB. How cardiologists present the benefits of percutaneous coronary interventions to patients with stable angina: a qualitative analysis. JAMA Intern Med. 2014;174(10):1614-21.
- Rothberg MB. Coronary artery disease as clogged pipes: a misconceptual model. Circ Cardiovasc Qual Outcomes. 2013;6(1):129-32.
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.
The large national cardiology conferences may attract the majority of cardiologists in the entire country to one place. So, hey, if you’re going to have a heart attack, that would seem to be the place to do it. And indeed, that’s when the American Heart Association president had his, within hours of his presidential address. With so many of the nation’s top cardiologists at the conference, maybe that’s a bad time to go into cardiac arrest anywhere else, though. You don’t know, until you put it to the test.
To their surprise, they found substantially lower mortality among those going into cardiac failure or cardiac arrest during the big national cardiology meetings. Why is the death rate lower when most of the cardiologists are away? One potential explanation is that the intensity of care may be lower, suggesting the harms of such care may unexpectedly outweigh the benefits. Their results echo paradoxical findings documented during a labor strike by Israeli physicians, during which mortality rates evidently dramatically fell. And it wasn’t just one strike. This has been looked at multiple times, and in all reported cases, mortality either stayed the same or decreased. In four of the seven cases, mortality dropped as a result of the strike, and in three, there was no significant change.
The fact is that many current medical practices have been found to offer no benefit, and, in fact, potential harms. Even physicians themselves estimate that about one-fifth of medical care is unnecessary. A national summit was convened by the joint commission that accredits hospitals and the American Medical Association to identify areas of overuse—treatments that provide zero or negligible benefit—potentially exposing patients to the risk of harm for nothing. They called out five practices: for example, prescribing antibiotics for viral upper respiratory tract infections, spending a billion dollars prescribing drugs that don’t work (and if anything just make things worse). But another overused practice they identified was elective percutaneous coronary intervention––in other words, angioplasty and stents.
Just to get everyone on the same page before we dive in, coronary artery disease, the #1 killer of men and women, involves blockages in the blood vessels that supply the heart muscle itself. Low blood flow can lead to a type of chest pain called angina or, if severe enough, to a heart attack. Plant-based diets and lifestyle programs have been shown to reverse these blockages by treating the cause of why our arteries are clogging up in the first place. But, for those unable or unwilling to change their diets, there are drugs that can help, as well as more invasive treatments such as open-heart surgery to try to bypass the blockage, or percutaneous coronary intervention. That’s when doctors insert small balloons or metal tunnels, called stents, up through the large blood vessels typically in the groin, and thread them all the way up into the heart. That way, you can then get inside the blocked vessels, and try to open them up and prop them open. During a heart attack this can be lifesaving. But hundreds of thousands of these procedures are done every year for stable angina, meaning on a non-emergency basis, which can relieve symptoms but doesn’t actually reduce your risk of having or dying from a heart attack in the future.
However, not everyone knows that. They mistakenly think the procedure offers more than just symptom relief. That’s one of the reasons I’m doing this video series. As Harvard put it, stents are for pain, not protection. But then, unbelievably, it was discovered that stents may not even help with pain, as revealed in this double-blind, randomized controlled trial. Wait, you can blind people to the active treatment in drug trials by giving them a placebo sugar pill, but wouldn’t you kinda notice if you got surgery or not, whether or not they cut into your groin? Not if you got sham surgery—placebo surgery—where they cut into everyone, thread up the catheter, and at the last moment, randomly actually do or do not actually place the actual stent. And those who got the fake surgery did just as well as those who got the regular surgery. Wait, there are no benefits to angioplasty and stents outside of an emergency setting? Doesn’t prevent heart attacks, doesn’t enable you to live longer, and doesn’t even help with symptoms? And since the procedure carries risks—including death—maybe stents should be used only for people who are actively having heart attacks. But wait, so hundreds of thousands of people are getting these operations for nothing? How do the doctors justify it? Is it just greed? How do they get patients to sign up it? Do they just not tell them the truth? And wait, why doesn’t it work? After all, you are opening up a blocked artery. There are just so many questions, which we’ll start addressing next.
Please consider volunteering to help out on the site.
- Mano T, Yamamoto K. Report of the American College of Cardiology (ACC) Scientific Sessions 2016, Chicago. Circ J. 2016;80(6):1308-13.
- Redberg RF. Cardiac patient outcomes during national cardiology meetings. JAMA Intern Med. 2015;175(2):245.
- Seo Y. Report of the American Heart Association (AHA) Scientific Session 2017, Anaheim, California. Circ J. 2018;82(2):323-7.
- Jena AB, Prasad V, Goldman DP, Romley J. Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings. JAMA Intern Med. 2015;175(2):237-44.
- McCarthy M. Death rate is lower in high risk heart patients at US teaching hospitals during cardiology conferences. BMJ. 2014;349:g7858.
- Siegel-Itzkovich J. Doctors' strike in Israel may be good for health. BMJ. 2000;320(7249):1561.
- Cunningham SA, Mitchell K, Narayan KM, Yusuf S. Doctors' strikes and mortality: a review. Soc Sci Med. 2008;67(11):1784-8.
- Morgan DJ, Dhruva SS, Coon ER, Wright SM, Korenstein D. 2018 Update on Medical Overuse. JAMA Intern Med. 2019;179(2):240-6.
- Lyu H, Xu T, Brotman D, et al. Overtreatment in the United States. PLoS One. 2017;12(9):e0181970.
- Proceedings from the National Summit on Overuse. 24 September 2012. The Joint Commission. Physician Consortium for Performance Improvement.
- Esselstyn CB. A plant-based diet and coronary artery disease: a mandate for effective therapy. J Geriatr Cardiol. 2017;14(5):317-20.
- Summaries for patients. Patients' and cardiologists' beliefs about a common heart procedure. Ann Intern Med. 2010;153(5):I46.
- Rothberg MB, Scherer L, Kashef MA, et al. The effect of information presentation on beliefs about the benefits of elective percutaneous coronary intervention. JAMA Intern Med. 2014;174(10):1623-9.
- COURAGE to make choices. Harvard Heart Letter. June 2007.
- Kolata G. ‘Unbelievable’: Heart Stents Fail to Ease Chest Pain. The New York Times. November 2, 2017.
- Al-Lamee R, Thompson D, Dehbi HM, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet. 2018;391(10115):31-40.
- Brown DL, Redberg RF. Last nail in the coffin for PCI in stable angina?. Lancet. 2018;391(10115):3-4.
- Coey D. Physicians’ Financial Incentives and Treatment Choices in Heart Attack Management. Quant Econom. 2015;6(3):703-48.
- Goff SL, Mazor KM, Ting HH, Kleppel R, Rothberg MB. How cardiologists present the benefits of percutaneous coronary interventions to patients with stable angina: a qualitative analysis. JAMA Intern Med. 2014;174(10):1614-21.
- Rothberg MB. Coronary artery disease as clogged pipes: a misconceptual model. Circ Cardiovasc Qual Outcomes. 2013;6(1):129-32.
Video production by Glass Entertainment
Motion graphics by Avocado Video
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Title
Do Angioplasty Heart Stent Procedures Work?
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Content URLDoctor's Note
Hold on. Why doesn’t opening up—and even propping open—a blocked coronary artery help? I address that next. This is the first video in a seven-part series on stents. Stay tuned for:
- Why Angioplasty Heart Stents Don’t Work Better
- The Risks of Heart Stents
- Angioplasty Heart Stent Risks vs. Benefits
- 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
All of these videos are available on a digital download of a webinar I did last year, which also includes a series on statins. 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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