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When You Really Need a Stent (or Don't)

A stent can save your life during a heart attack. But new research reveals whether it can prevent one

spinner image doctor showing atheroma plaque and stent placement images on computer screens
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Almost a million Americans each year get a stent — a tiny mesh tube, typically metal, that props open a clogged artery. If you have heart disease, your doctor may recommend one for you, too. But whether you need it is another question.

While the research is clear that stents save lives if inserted during a heart attack, “for most patients with stable heart disease, there's no good evidence that it can save their life or improve their symptoms any more than medication and lifestyle changes,” says Frederick Welt, M.D., chair of the American College of Cardiology's Interventional Section. That evidence includes a major study, published last year in the New England Journal of Medicine, which found that people with heart disease who were treated with medications and lifestyle advice were no more at risk of a heart attack or death than those who got a stent.

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That doesn't mean you should avoid stents entirely — again, under the right circumstances, they can save your life, says Welt. Here's the latest thinking on when you need one, and when you don't.

Early days of stents

Stenting, which first became widely available in the 1980s, gained steam when it became clear that it was an effective emergency treatment for heart attacks. In this procedure, also known as an angioplasty, a thin balloon is inflated in the narrowed artery and a stent is inserted to keep the vessel open.

From there, doctors assumed that stents would help with other blockages due to heart disease. “It seemed to make sense intuitively, because the coronary arteries provide blood and oxygen to the heart muscle, and if they're narrowed because of plaque, you can develop symptoms of heart disease such as shortness of breath or chest pain,” explains Rita Redberg, M.D., a preventive cardiologist at the University of California San Francisco and editor of JAMA Internal Medicine.

But that thinking was turned on its head in 2007, when a study in the New England Journal of Medicine of over 2,000 people with heart disease found that those who had a stent implanted as a preventive measure had similar rates of heart attack and death as those who just took medication.

Since then, other studies have found similar results. “Unfortunately, we started using stents before we really had evidence that they worked to prevent heart disease,” says Redberg. “Companies spent billions of dollars on technology and training and physicians really were taught to believe that this was the right thing to do.” But, she adds, “now research has caught up with us, and many people in this country are still getting stents when they don't need them.”

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But while some of the pressure to put in stents of questionable value may be physician-driven, doctors say pressure also comes from patients who remain convinced — especially when they see blocked vessels on heart imaging tests — that a stent could fix the problem in front of them.

When you should (or shouldn't) get a stent

If you are having a heart attack, a stent is absolutely needed, stresses Donald Lloyd-Jones, M.D., chair of the Department of Preventive Medicine at the Northwestern University Feinberg School of Medicine in Chicago. Since a clot has completely blocked an artery, your heart muscle is starved of oxygen. This can lead to permanent damage if it's not treated quickly.

But you probably don't need a stent if you have stable heart disease. This means that you while you do have symptoms like chest pain or shortness of breath, they only occur when you exercise or feel stressed, and they respond to medications. “We know that some of these patients will go on to have heart attacks, but putting a stent into the blood vessel with the blockage won't prevent a heart attack from happening,” explains Welt. Why not? “There's usually disease all along that blood vessel, so it's not easy to predict where the plaque in it will rupture and cause a heart attack. You could place a stent in one spot, and have the heart attack occur a centimeter downstream."

In these situations, lifestyle changes — plus medications like beta-blockers to control blood pressure, statins to lower cholesterol, and aspirin to prevent blood clots — are at least as effective. A December 2016 review in JAMA Internal Medicine found that this approach could reduce the number of angioplasties by almost 80 percent.

What's more, Lloyd-Jones notes that stents come with “small but real complication rates.” These include discomfort and bleeding, as well as even small tears around the stenting site. Getting one also requires that you take high amounts of medications such as blood thinners to help with healing, adds Lloyd-Jones, who notes that such drugs can also sometimes cause bleeding problems.

It does make sense to consider a stent, however, if your symptoms such as chest pain aren't relieved by medication and lifestyle changes, says Khaled Ziada, M.D., an interventional cardiologist at the Cleveland Clinic. In these cases, or if symptoms happen even at rest, a stent may help make you feel better.

Last year's New England Journal of Medicine study did show that stents in this particular group of patients helped relieve symptoms and improved their quality of life. But “we don't lose by having patients try medicine and lifestyle first — we know it doesn't raise their risk of heart attack or death,” Ziada stresses. “A lot of my patients still think that if they have one or two episodes of chest pain, they automatically need a stent put in. That's truly not the case. For most people, lifestyle and drug therapy are the best medicine."

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