Are Coronary Stents Necessary In Patients With Stable Coronary Artery Disease?

Are Coronary Stents Necessary In Patients With Stable Coronary Artery Disease?

Years ago I was chatting with the nurse on the cardiac telemetry unit. I asked her what she would want if she was known to have a 90% blockage in her left anterior descending artery, aka the widowmaker, but had no symptoms. I reminded her that the literature had clearly demonstrated that coronary revascularization in stable coronary artery disease (CAD) did not reduce the risk of death or heart attack, but did decrease angina (chest pain). Her answer was clear. She stated repeatedly that she would definitely want to have her artery fixed with a stent if there was a blockage even if she was asymptomatic.

There’s a lot of buzz in the media this weekend with regards to the ISCHEMIA trial. This recently presented study by the American Heart Association looked at thousands of patients who were proven to have blockages in their coronary arteries. They were randomized to either an invasive strategy, which could include revascularization via stents or bypass surgery, or an initial strategy of medical management. The study did not demonstrate any significant advantage to the invasive strategy with regards to major cardiac events such as death, heart attack, cardiac arrest. The take-home of the study suggests that patients with stable coronary artery disease can be safely managed medically.

Certain high-risk patients were excluded from the study, such as patients with blockage of the left main coronary artery and those who had severely reduced cardiac function. Patients who had previous bypass surgery or stents within the past year were also excluded.

It’s important to remember that the study looked at patients who had stable coronary artery disease, but did not include those with active heart attacks. In patients with active heart attacks, there is no controversy over the benefits of stents.

This study should give doctors more confidence to focus initially on optimizing medical management of stable CAD patients and to delay invasive procedures for patients who do not have high risk features. Given what we know about the benefits of lifestyle modification such as plant-based diet, regular exercise, and stress reduction a conservative management approach may be a great initial option for patients with stable CAD.

What are your thoughts about the use of stents in patients with stable CAD? If your doctor found a severe blockage in your heart would you be comfortable with a conservative, noninvasive approach?

https://www.acc.org/…/clinical-tr…/2019/11/15/17/27/ischemia