
Heart Stents Fail to Ease Chest Pain - denzil_correa
https://www.nytimes.com/2017/11/02/health/heart-disease-stents.html?_r=0
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mcguire
" _For the study [...] recruited 200 patients with a profoundly blocked
coronary artery and chest pain severe enough to limit physical activity,
common reasons for inserting a stent._

" _All were treated for six weeks with drugs to reduce the risk of a heart
attack, like aspirin, a statin and a blood pressure drug, as well as
medications that relieve chest pain by slowing the heart or opening blood
vessels._

" _Then the subjects had a procedure: a real or fake insertion of a stent.
This is one of the few studies in cardiology in which a sham procedure was
given to controls who were then compared to patients receiving the actual
treatment._

" _In both groups, doctors threaded a catheter through the groin or wrist of
the patient and, with X-ray guidance, up to the blocked artery. Once the
catheter reached the blockage, the doctor inserted a stent or, if the patient
was getting the sham procedure, simply pulled the catheter out._ "

I would really like to know how they got that study past the assorted ethics
committees.

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trevyn
"Stenting is so accepted that American cardiologists said they were amazed
ethics boards agreed to a study with a sham control group.

But in the United Kingdom, said Dr. Davies, getting approval for the study was
not so difficult. Neither was it difficult to find patients.

“There are many people who are open to research, and if you tell them you are
exploring a question, people agree,” he said. Nonetheless, it took him three
and a half years to find the subjects for his study.

Ethics boards at many American hospitals probably would resist, since giving
such patients fake procedures “flies in the face of guidelines,” Dr. Boden
said."

~~~
jogjayr
In a practical sense, I wonder how they'd successfully do it in the US.

Stents cost on the order of $11k-$44k per the article. Wouldn't you just know
from looking at your bill afterward whether you got the stent or not?

~~~
maxerickson
A simple way around that would be to pay for them so that no patient was
billed for one.

~~~
robgough
Is there not a problem that in the US it would encourage people who otherwise
couldn't afford the operation to opt for the "riskier" trial, even if they'd
really prefer not to. Whereas in the UK, they would have received the
operation free in or out of the trial, therefore the patients financial
situation wouldn't factor in to their decision to join. Which feels
significantly more ethical to me.

~~~
jdavis703
In theory you either have insurance that should cover this (more than 90% of
Americans are covered), or else you'd be too poor to really even be able to
afford such an operation or medical care. The system sucks, but I don't think
the way the system is set up would cause a significant number of people to use
free research for medical alternatives.

~~~
jogjayr
Even if you have insurance you get a statement from your insurance provider
detailing how much everything cost and how much of it insurance paid for.

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graeham
Stents are an incredible piece of engineering, but probably are over-used
(particularly in the USA). There are a few issues at play:

-Chest pain

-Artery narrowing

-Heart attack risk

They aren't the same, although there is correlation between each. The original
idea behind stents was to stabilise vessels in the process of a heart attack.
They are increasingly used in a preventative way - but the problem is there
aren't very many or good tools to tell how at risk an individual is to a heart
attack.

Another major problem (as the article mentions) is that stents improve the
situation in one artery, but most patients that need a stent have
atherosclerosis in multiple vessels. This likely explains why the chest pain
remains.

~~~
epmaybe
I'm a little confused by this. Patients can get stents in multiple arteries
during one cath lab session. Generally it's a diagnostic cath at first,
finding all blockages, and deciding which vessels should be ballooned/stented.
I've been in multiple procedures (shadowing, not performing) where they did 2+
vessels.

~~~
graeham
Agreed that multiple stents and multiple vessels can be stented in one cath
session. My point was more that there isn't very strong evidence or criteria
for what constitutes a vessel that should be stented versus which should not.
Worse, plaques are dynamic – what looks benign today could rupture and cause a
complete/near occlusion. Rupture and subsequent thrombosis is more dangerous
than stenosis itself.

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bluetwo
Previous research showed that stents increase lifespan only in patients who
have already had a heart attack.

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tomohawk
They only assessed the patients after 6 weeks. It would be interesting what a
longer follow up of the patients would reveal.

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thomastjeffery
A 6-week study of 200 people.

Why is this news?

~~~
starchild_3001
I once read a study that the half life of truth in medicine is 20 years.
Namely in 20 years roughly half of the things we identified as truth are
overturned. Examples? Fat clogs arteries. Cholesterol clogs arteries. LDL
causes heart disease. High blood pressure causes atherosclerosis. All of these
"truths" have been debunked in the last 30 years or so. Apparently there are
many more. Stents save lives? There's 50% chance you'll be proven wrong in ~20
years! Maybe much sooner.

~~~
robbiep
When I was at med school 7 years ago we were told for years. I thought it was
just a way of saying that medical knowledge increases so quickly, but then
whilst I was there we had:

\- Total change in how we manage chest pain/heart attacks (moving from
previous full/partial thickness infarction to STEMI/NSTEMI and totally
revising treatment algorithms

\- Introduction of ipilumimab for melanoma (changed metastatic melanoma from a
condition with 6 month average survival to 5 years/chronic disease

\- Introduction of cure for help c (previously followed the rule of 20 and it
was a chronic disease)

\- Total revision of food pyramid

\- Multitude others

I believe 4-6 years. So much changes, without CPD/CME you are useless.

