Stents are not the magic wand

Stents are not the magic wand

Cardiologists in India say that The Lancet study has not broken new ground

The tenuous trajectory of stents or the tiny mesh-like wires used to open blockages in blood vessels has suffered a body blow. The first jolt was when earlier this year, the government capped their prices. And now, a research paper (November 2) published in the peer-reviewed general medicine journal, The Lancet, has claimed (on the basis of an experiment) that while inserting stents improves blood supply, it does almost nothing to ease angina pain, which results from reduced flow of blood to the heart.

For the study (http://bit.ly/2ACqe35), 230 participants with stable angina were recruited, of whom 195 were randomly assigned surgical intervention. Of them, 105 were given stents — percutaneous coronary intervention (PCI) — and 95 (the control group), were given placebo procedures. The study had a double blind in that neither the participants nor the doctors, who subsequently followed them for six weeks, knew who had had what procedure.

The claims are significant as about 500,000 heart patients worldwide have stents inserted to relieve chest pain. In India, this year alone, 1.7 million died from heart-disease-related complications, according to the Global Burden of Disease report.

Nothing new to add

However, cardiologists in India are in broad agreement with the findings of study, say that it is not a novel find and stress its limitations. Stents, they emphasise, aren’t the be-all and end-all of cardiac ailments.

“The study doesn’t tell us something that we didn’t know or something that hasn’t been debated and looked into. In fact this is the protocol that we follow. Doctors here are aware that stents alone don’t benefit people with chest pain. This is exactly what The Lancet report too states,” says cardiologist and chairman-cum-managing director of Medanta, the Medicity, Dr. Naresh Trehan.

“The study, besides being a very superficial and preliminary one, hasn’t broken new ground,” he explains.

He adds that people with up to 80% of heart blocks show limited improvement when put on medical therapy. “However, this doesn’t apply to people who have blockages in the left arteries. In this case we would recommend using a stent. The left anterior descending artery (LAD) is supposed to be the most important vessel for maintenance of blood supply to the heart,” he adds.

Moreover, the study does not specifically study the implications for the Indian population. “Yes, a validation for [the] Indian population is not available. That is because we face multiple problems including treating rural patients, who don’t follow-up as often as they should,” Dr. Trehan says.

Leading cause of mortality

However the study has renewed interest in cardiovascular diseases.

“There isn’t anything new that the study is reporting,” says cardiologist and Indian Medical Association head, Dr. K.K. Aggarwal. “Cardiovascular diseases have now become the leading cause of mortality in India. What this study has done is to bring back attention to the disease. We as doctors know that there isn’t much that can be done by using stents for stable angina. They work for people who have had a sudden heart attack. This is a known fact.”

Rather than focussing on stents alone, there are gains to be made in sprucing up so-called “predictive health” approaches. “Stents have very limited applications and it is something that doctors here in India understand and advice accordingly,” says Dr. R.R. Kasliwal, a Delhi-based cardiologist.

“We in India have now gone a step further and started something called predictive health which deals with health mapping to offer preventing and early detection of heart diseases.

“The positive development that we have in terms of stenting is that we have a price ceiling which allows doctors to rationally advise patients on the costs of cardiac intervention.”