Why are doctors killing or stroking out thousands of people a year for nothing? How do doctors even convince patients to sign up for procedures that are all risk without benefit?
The Risks of Heart Stents
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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.
Millions of people have gotten stents for stable coronary artery disease, yet we now know that for such patients, angioplasty and stent placement doesn’t actually prevent heart attacks, doesn’t even offer long-term angina pain relief, and doesn’t improve survival. Why? Because the most dangerous plaques—the ones most vulnerable to rupture leading to a heart attack—are not the ones doctors put stents in, not the ones often even seen on angiogram to be obstructing blood flow. So “[w]e need to avoid the ’therapeutic illusion’ that we are accomplishing more than is shown by the evidence.” It looks great. You’re opening up blood flow. But if it doesn’t actually help, why do it?
And we’re not just talking about billions of dollars wasted. Stent placement and the blood-thinner drugs you have to go on can cause complications, including heart failure, stroke, and death. The risks are relatively low; less than a 1 percent chance it will kill you or stroke you out. The 15 percent risk of heart attack is only if your stent clogs off at a later date, which only happens in about 1 percent in the near-term. The 13 percent kidney injury is legit, though, due to the dyes they have to inject, but that typically just heals on its own. The most serious complications, like death, only happen in about 1 in 150 cases. But you have to multiply that by the fact that hundreds of thousands of the procedures are being done every year.
In an emergency setting, like while you’re actively having a heart attack, angioplasty can be lifesaving, but these hundreds of thousands are for stable coronary artery disease, for which there appears to be no benefits. So then, doctors are killing or stroking out thousands of people a year for nothing. And that’s not even counting the tens of thousands of silent mini-strokes that may contribute to cognitive decline caused by these procedures. Between 11 and 17 percent of people who go through angioplasty or stenting come away with new brain lesions. That’s like up to one in six.
How do doctors convince patients to sign up for these when they don’t lower the risk of death, or heart attack, or offer long-term symptom relief? Apparently by conveniently failing to inform their patients that they don’t lower the risk of death or heart attack, or offer long-term symptom relief.
Cardiologists are aware of how little they help, but studies have consistently demonstrated that patients think stents will reduce their risk of heart attack or death. More than 70 percent of patients erroneously believed that stents would extend their life expectancy or prevent future heart attacks. That’s why this study was done—to figure out where patients are getting these crazy ideas from. And the answer is that many patients are being kept in the dark, pressured into procedures that won’t benefit them the way they think, by doctors that overstate the benefits and understate the risks. Why would they do that? Well, one reason could be because doctors may be paid per procedure. Doctors are paid more for offering stents than common sense diet and lifestyle changes.
Patients with stable coronary disease undergoing angioplasty and stent placement are frequently misinformed. Of 59 recorded conversations, only two included all seven elements of informed decision-making—in other words, telling people they have a choice, explaining the problem, discussing alternatives and the pros and cons, informing patients the procedure may not work, asking if they understand, even just asking if patients have any questions, and asking patients what they want to do. Only 3 percent of doctor-patient discussions about stents hit even just these basic elements. And that’s when the doctors knew they were being recorded. So, if anything, this may be like the best-case scenario. Only 3 percent! Quoting from the Cleveland Clinic Journal of Medicine, when it comes to angioplasty and stents, “[t]rue informed consent rarely occurs.”
No wonder that among the nearly 1,000 patients surveyed across 10 U.S. academic and community hospitals, just 1 percent knew the truth. Remarkably, some blame the patients for their ignorance: they’re the ones that “overestimate or misunderstand the benefits … such as patients with cancer who believe [their chemo] offers the potential for cure—the ‘therapeutic misconception.’”
Don’t look at the patients to find out why so many patients are accepting procedures with questionable benefits. “Patients think they are having life-saving procedures because medical professionals want them to believe that this is so.” Now, it’s not like those 95 percent of cardiologists are lying to their patients and saying that it will reduce their risk. They just happened to have conveniently omitted that little detail. But in the absence of information to the contrary, most patients are going to naturally assume that’s the case.
Why would they just assume that? Because patients have this crazy concept of “personal care”—that a physician’s first obligation is solely to the patient’s well-being. How naïve can you get? And so, in the absence of information, or even when presented with evidence to the contrary, patients tend to believe that treatments offered will be beneficial.
It’s true, even if you explicitly tell patients that stents do not reduce the risk of heart attacks. Yes, you can cut that misperception in half. That’s great that with two sentences you can dispel the myth in most people. But many participants continued to believe that angioplasty and stents prevent heart attacks, even when explicitly told they do not, along with a detailed explanation why. After all, why would doctors be pushing them if they didn’t help? That’s a good question, which we’ll address next.
Please consider volunteering to help out on the site.
- Mandrola J. Coronary Stents Humbled Yet Again in Stable CAD. Medscape. November 07, 2017.
- Khan SU, Singh M, Lone AN, et al. Meta-analysis of long-term outcomes of percutaneous coronary intervention versus medical therapy in stable coronary artery disease. Eur J Prev Cardiol. 2019;26(4):433-6.
- Weintraub WS, Boden WE. Reexamining the Efficacy and Value of Percutaneous Coronary Intervention for Patients With Stable Ischemic Heart Disease. JAMA Intern Med. 2016;176(8):1190-4.
- Dehmer GJ, Weaver D, Roe MT, et al. A contemporary view of diagnostic cardiac catheterization and percutaneous coronary intervention in the United States: a report from the CathPCI Registry of the National Cardiovascular Data Registry, 2010 through June 2011. J Am Coll Cardiol. 2012;60(20):2017-31.
- Mitchell JD, Brown DL. Harmonizing the Paradigm With the Data in Stable Coronary Artery Disease: A Review and Viewpoint. J Am Heart Assoc. 2017;6(11):e007006.
- Cutlip DE, Baim DS, Ho KK, et al. Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. Circulation. 2001;103(15):1967-71.
- Mehran R, Aymong ED, Nikolsky E, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol. 2004;44(7):1393-9.
- Gress DR. The problem with asymptomatic cerebral embolic complications in vascular procedures: what if they are not asymptomatic? J Am Coll Cardiol. 2012;60(17):1614-6.
- 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.
- Chandrasekharan DP, Taggart DP. Informed consent for interventions in stable coronary artery disease: problems, etiologies, and solutions. Eur J Cardiothorac Surg. 2011;39(6):912-7.
- Rothberg MB, Sivalingam SK, Kleppel R, Schweiger M, Hu B, Sepucha KR. Informed Decision Making for Percutaneous Coronary Intervention for Stable Coronary Disease. JAMA Intern Med. 2015;175(7):1199-206.
- Rothberg MB. PCI for stable angina: a missed opportunity for shared decision-making. Cleve Clin J Med. 2018;85(2):105-21.
- Whittle J, Fyfe R, Iles RD, Wildfong J. Patients are overoptimistic about PCI. BMJ. 2014;349:g5613.
- Fernandez A. Improving the quality of informed consent: it is not all about the risks. Ann Intern Med. 2010;153(5):342-3.
- Howard WG. The real reasons behind complex surgical procedures. BMJ. 2014;349:g6448.
- 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.
- 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.
- 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.
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.
Millions of people have gotten stents for stable coronary artery disease, yet we now know that for such patients, angioplasty and stent placement doesn’t actually prevent heart attacks, doesn’t even offer long-term angina pain relief, and doesn’t improve survival. Why? Because the most dangerous plaques—the ones most vulnerable to rupture leading to a heart attack—are not the ones doctors put stents in, not the ones often even seen on angiogram to be obstructing blood flow. So “[w]e need to avoid the ’therapeutic illusion’ that we are accomplishing more than is shown by the evidence.” It looks great. You’re opening up blood flow. But if it doesn’t actually help, why do it?
And we’re not just talking about billions of dollars wasted. Stent placement and the blood-thinner drugs you have to go on can cause complications, including heart failure, stroke, and death. The risks are relatively low; less than a 1 percent chance it will kill you or stroke you out. The 15 percent risk of heart attack is only if your stent clogs off at a later date, which only happens in about 1 percent in the near-term. The 13 percent kidney injury is legit, though, due to the dyes they have to inject, but that typically just heals on its own. The most serious complications, like death, only happen in about 1 in 150 cases. But you have to multiply that by the fact that hundreds of thousands of the procedures are being done every year.
In an emergency setting, like while you’re actively having a heart attack, angioplasty can be lifesaving, but these hundreds of thousands are for stable coronary artery disease, for which there appears to be no benefits. So then, doctors are killing or stroking out thousands of people a year for nothing. And that’s not even counting the tens of thousands of silent mini-strokes that may contribute to cognitive decline caused by these procedures. Between 11 and 17 percent of people who go through angioplasty or stenting come away with new brain lesions. That’s like up to one in six.
How do doctors convince patients to sign up for these when they don’t lower the risk of death, or heart attack, or offer long-term symptom relief? Apparently by conveniently failing to inform their patients that they don’t lower the risk of death or heart attack, or offer long-term symptom relief.
Cardiologists are aware of how little they help, but studies have consistently demonstrated that patients think stents will reduce their risk of heart attack or death. More than 70 percent of patients erroneously believed that stents would extend their life expectancy or prevent future heart attacks. That’s why this study was done—to figure out where patients are getting these crazy ideas from. And the answer is that many patients are being kept in the dark, pressured into procedures that won’t benefit them the way they think, by doctors that overstate the benefits and understate the risks. Why would they do that? Well, one reason could be because doctors may be paid per procedure. Doctors are paid more for offering stents than common sense diet and lifestyle changes.
Patients with stable coronary disease undergoing angioplasty and stent placement are frequently misinformed. Of 59 recorded conversations, only two included all seven elements of informed decision-making—in other words, telling people they have a choice, explaining the problem, discussing alternatives and the pros and cons, informing patients the procedure may not work, asking if they understand, even just asking if patients have any questions, and asking patients what they want to do. Only 3 percent of doctor-patient discussions about stents hit even just these basic elements. And that’s when the doctors knew they were being recorded. So, if anything, this may be like the best-case scenario. Only 3 percent! Quoting from the Cleveland Clinic Journal of Medicine, when it comes to angioplasty and stents, “[t]rue informed consent rarely occurs.”
No wonder that among the nearly 1,000 patients surveyed across 10 U.S. academic and community hospitals, just 1 percent knew the truth. Remarkably, some blame the patients for their ignorance: they’re the ones that “overestimate or misunderstand the benefits … such as patients with cancer who believe [their chemo] offers the potential for cure—the ‘therapeutic misconception.’”
Don’t look at the patients to find out why so many patients are accepting procedures with questionable benefits. “Patients think they are having life-saving procedures because medical professionals want them to believe that this is so.” Now, it’s not like those 95 percent of cardiologists are lying to their patients and saying that it will reduce their risk. They just happened to have conveniently omitted that little detail. But in the absence of information to the contrary, most patients are going to naturally assume that’s the case.
Why would they just assume that? Because patients have this crazy concept of “personal care”—that a physician’s first obligation is solely to the patient’s well-being. How naïve can you get? And so, in the absence of information, or even when presented with evidence to the contrary, patients tend to believe that treatments offered will be beneficial.
It’s true, even if you explicitly tell patients that stents do not reduce the risk of heart attacks. Yes, you can cut that misperception in half. That’s great that with two sentences you can dispel the myth in most people. But many participants continued to believe that angioplasty and stents prevent heart attacks, even when explicitly told they do not, along with a detailed explanation why. After all, why would doctors be pushing them if they didn’t help? That’s a good question, which we’ll address next.
Please consider volunteering to help out on the site.
- Mandrola J. Coronary Stents Humbled Yet Again in Stable CAD. Medscape. November 07, 2017.
- Khan SU, Singh M, Lone AN, et al. Meta-analysis of long-term outcomes of percutaneous coronary intervention versus medical therapy in stable coronary artery disease. Eur J Prev Cardiol. 2019;26(4):433-6.
- Weintraub WS, Boden WE. Reexamining the Efficacy and Value of Percutaneous Coronary Intervention for Patients With Stable Ischemic Heart Disease. JAMA Intern Med. 2016;176(8):1190-4.
- Dehmer GJ, Weaver D, Roe MT, et al. A contemporary view of diagnostic cardiac catheterization and percutaneous coronary intervention in the United States: a report from the CathPCI Registry of the National Cardiovascular Data Registry, 2010 through June 2011. J Am Coll Cardiol. 2012;60(20):2017-31.
- Mitchell JD, Brown DL. Harmonizing the Paradigm With the Data in Stable Coronary Artery Disease: A Review and Viewpoint. J Am Heart Assoc. 2017;6(11):e007006.
- Cutlip DE, Baim DS, Ho KK, et al. Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. Circulation. 2001;103(15):1967-71.
- Mehran R, Aymong ED, Nikolsky E, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol. 2004;44(7):1393-9.
- Gress DR. The problem with asymptomatic cerebral embolic complications in vascular procedures: what if they are not asymptomatic? J Am Coll Cardiol. 2012;60(17):1614-6.
- 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.
- Chandrasekharan DP, Taggart DP. Informed consent for interventions in stable coronary artery disease: problems, etiologies, and solutions. Eur J Cardiothorac Surg. 2011;39(6):912-7.
- Rothberg MB, Sivalingam SK, Kleppel R, Schweiger M, Hu B, Sepucha KR. Informed Decision Making for Percutaneous Coronary Intervention for Stable Coronary Disease. JAMA Intern Med. 2015;175(7):1199-206.
- Rothberg MB. PCI for stable angina: a missed opportunity for shared decision-making. Cleve Clin J Med. 2018;85(2):105-21.
- Whittle J, Fyfe R, Iles RD, Wildfong J. Patients are overoptimistic about PCI. BMJ. 2014;349:g5613.
- Fernandez A. Improving the quality of informed consent: it is not all about the risks. Ann Intern Med. 2010;153(5):342-3.
- Howard WG. The real reasons behind complex surgical procedures. BMJ. 2014;349:g6448.
- 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.
- 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.
- 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.
Video production by Glass Entertainment
Motion graphics by Avocado Video
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Title
The Risks of Heart Stents
LicenseCreative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)
Content URLDoctor's Note
Starting to get angry yet? What do physicians have to say for themselves? What do stent companies have to say? That’s the subject of my next video: Angioplasty Heart Stent Risks vs. Benefits.
If you missed the first few in this seven-part series, see Do Angioplasty Heart Stent Procedures Work? and Why Angioplasty Heart Stents Don’t Work Better.
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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