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Who Really Needs a Stent?

Fewer people than you might think

En español | The journey leading to a stent starts when a doctor orders a stress test, which usually includes an imaging procedure that may reveal whether any heart arteries are blocked. "The best way to describe a stress test is that it's really like a mammogram for heart disease or a colonoscopy for heart disease," says Paul Chan, M.D., a cardiologist at St. Luke's Mid America Heart and Vascular Institute in Kansas City, Mo.

See also: Some stents do more harm than good.

If the patient has stable chest pain — called angina — or if the stress test shows serious blockages, the doctor may want an angiogram, which provides a detailed picture of the arteries.

During an angiogram, patients are kept lightly sedated while a catheter is threaded through an incision in an artery in the groin, allowing a special dye to be injected in the blood vessels surrounding the heart. Then x-ray images are taken.

If the doctor finds a blockage, he may decide right then to perform an angioplasty, pushing the artery open with a small balloon. Then, a metal mesh tube called a stent is often inserted to keep the vessel open.

These advanced procedures are considered elective, because the patient must ultimately consent to an angioplasty and stent.

To make sure they're deciding wisely — and with a clear head — patients should sit down with their doctor before the angiogram and discuss their options, Chan says. He says there are two key questions to consider:

1. How abnormal was my stress test? Was it slightly abnormal or very abnormal?

2. Do I have symptoms? Are my symptoms severely limiting my daily life?

Chan says some patients suffer from angina that kicks in every time they exert themselves, while others feel no pain, although they have some artery blockage.

Even if the angiogram reveals a blockage, if the patient's angina is mild, the problem often can be managed with medicines and lifestyle changes including exercise, a healthy diet and not smoking. Before the angiogram, the patient may want to specify he would prefer to try these options first, before a stent is inserted.

Diagram of a stent inside a cut away view of an  artery.

Many stents are being put in patients unnecessarily, costing the health care system billions. — Photo by Science Picture Co./Getty Images

Patients meanwhile need to understand there is a small risk — about 1 in 1,000 — of complications when a stent is inserted, Chan says. And, he says, up to 4 percent of patients may suffer from bleeding problems afterward.

Financial considerations may come into play for patients who have large insurance copays, given that a stent procedure can cost between $10,000 and $20,000, Chan says.

Studies show angioplasty with a stent is no better than treatment with medications for preventing future heart attacks or death, but the procedure can provide real benefit when used judiciously, Chan says.

Also of interest: Eat for a healthy heart. >>

Michael Haederle is a freelance writer whose work has appeared in People, the New York Times and the Los Angeles Times.

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