The dark side, and upside, of stents

I have been following the "stent scandals and controversies" very closely in your paper. I treat diabetics among whom the incidence of coronary heart disease and heart attacks is very high. Most long-term diabetics will need a consultation with a cardiologist sometime during their life, either to prevent heart attacks or to treat one that has already happened.

I remember when coronary artery bypass surgery was considered a preferred treatment over stents for diabetics but that was way before stents became commonplace, particularly the drug eluting ones. In the time before stents became all the rage, cardiologists were cautious about the procedure, placing one or two stents at one sitting, but with experience the confidence of the interventionists grew and they began to insert as many as three stents at one sitting.

Whenever my diabetic patients return to me after one of these procedures, I am struck by how routine stenting has become. A week or two after the procedure my patients are up and about and during a visit to my office they are quite worshipful of their cardiologists. My own subject of specialty, endocrinology, has few gimmicks or money-fetching procedures and my diabetic patients are my peep holes to the mighty and highly regarded world of interventional cardiology.

Today all kinds of jujitsu are possible in the realm of stenting, with stents being inserted into stents and one artery being made patent with 5 stents in place. When my patients tell me proudly that they have five stents in one artery or a total of ten stents distributed over their various coronary arteries, I dare not belittle this achievement of modern technology by paying it no attention. I always give these stories the appropriate gasps in my office, my eyes hopefully reflecting my amazement, but I cannot help what my sagacious head exasperatedly takes note: that stents have made it seem like coronary artery disease, often a lethal and progressive condition, is endlessly manageable and stents have corrupted my patients' desire to change their life styles.

"Here I am in my office," I would tell myself, "trying to get these patients to give up that ice cream or that apple pie, and in comes the cardiologist with his catheter and his stents to perform his miracle after which, the patients emerge from the cath lab with a new lease on life, reassured the apple pie or the ice cream could do them no harm and if it did, there is always another stent to be inserted where the harm has been wrought, or a stent within a stent or a row of pretty little stents."

No joke! To most American patients, stents are wonderful devices; like liquid Drano to the plumber, so the stents to the cardiologists, these patients imagine. But in reality after stents are inserted dangerous clots can form within them or opened up arteries can get reclogged or patients consigned to taking powerful blood thinners for the rest of their lives can bleed into their brains or other parts of their bodies, suffering new complications.

It is not that my friends in cardiology do not explain these tragic side effects of stent insertion to their patients; it is simply that many American patients, in shock and awe about the latest technologies to arrive on the horizon, will submit themselves with utmost optimism to procedures they have not completely researched or understood and even when their doctors are cautioning them about the dark side of the technologies used, these patients will only half hear what is said, their ears dulled by the sound of tall, frothy milk shakes, they dream themselves sucking, through long straws, or cigarettes they hear themselves drawing on, most pleasurably, after technology has made them whole.

Such is the fascination for technology in America and the zest for good living that doctors who are doing the yeoman work of changing bad lifestyles, one patient at a time, are essentially losers in the financial arena. Insurance companies that talk a mile a minute about increasing reimbursements for primary care doctors and for preventive medicine, have done so reluctantly, throwing a morsel at a time to the not-so-glamorous specialties. Hospitals love their interventional cardiologists more then their infectious diseases specialists, because the former can make the hospitals' stars shine in the world of advertisement and publicity while the latter have to mostly resign themselves to "unsung and unknown" status. I have to assert that interventional cardiology, as a glamorous profession, is not an invention of the cardiologist alone; instead, responsibility for this exalted status has to be shared by society as a whole, with patients demanding quick fixes for all their ailments, insurance companies, for quite a long while, paying heftily for these quick fixes and hospitals lusting after those payments.

Hence I am astonished that the federal government and a legion of lawyers have now descended on interventional cardiologists and have discovered this whole new entity called "unneeded stenting". I am especially surprised because, nothing is cut and dry in the world of coronary artery disease and stents. In medicine, clinical research or research done in the lab is not always translated fully or understandably or indisputably to the field of practice and for every article an expert can quote to support a certain set of favorable conditions for a procedure, another can quote ten articles in opposition.

Coronary artery disease is also a minefield of contradictions. The intensity of chest pain does not always correlate with the degree of narrowing of the heart vessels; some patients with not so narrow vessels suffering worse symptoms than ones with severely narrow arteries and although medical treatment is now preferred for blood vessels not significantly narrow, medical treatment may not be acceptable to a lot of patients, especially those in high-profile professions, some of them lawyers, who are unwilling to swallow a bunch of pills daily to keep their hearts going or patients who find the side effects of these drugs unacceptable. Besides "narrowing," until most recently, has merely been a visual estimate, not an exact calculation. Expressed as a percent, it is liable to interpretation and calculating it more exactly is an evolving science. In the face of these facts, the bureaucratic and legal brouhaha about unnecessary stents and patients harmed seems sorely in need of a balance in perspective.

Since America is a land of extremes where the rise to the top, of a person, a profession, a gadget or a procedure can be meteoric and the fall to the bottom of the same entities can be sudden and stunning, the past exaggerated celebration of interventional cardiologists and the very recent witch hunt for the same, should be squarely placed in the realm of America's propensity for swinging the pendulum from one type of foolishness to another. The witch hunt may reap some millions for insurance companies, including for the federal government, whose pockets are to let, but it will chill cardiology, that has in reality, done wonders for American longevity.

Remember when people dropped dead from heart attacks in droves? Many still do but not in such staggering numbers as in the past and that is because cardiologists with their inventions and their derring-do have changed the math for all of us. Even those not in favor of easy or careless interventions to the heart must admit this fact.

Are there some cardiologists who have placed unnecessary stents? Perhaps. But the zeal of head hunters to dredge and decapitate every last errant cardiologist and the predictable over enthusiasm of stingy insurance companies to regulate and extirpate one more life saving procedure is bad news for heart patients. Many could die an all American death while sipping their milk shakes and smoking their cigarettes because cardiologists, too terrified of sanctimonious bureaucrats and jail cells, may allow stents to go the way of phone booths and phonographs.

Usha Nellore, Bel Air

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