Angioplasty: Ending Inappropriate Use

Angioplasty and stenting may be overused

The COURAGE study reported in 2007 that angioplasty and inserting stents, or PCI (percutaneous coronary intervention), provided temporary relief from angina, but did not result in fewer deaths, myocardial infarction, or cardiovascular events than medication and lifestyle changes. The OAT clinical study indicated that for high-risk patients with total occlusion of the infarct-related artery, PCI conducted after the myocardial event did not reduce the risk of death, re-infarction, or heart failure.

The data were a shock to many cardiologists, who saw symptomatic relief in patients and have been performing angioplasties and inserting stents in a good-faith effort to help improve quality of life.

Despite this information and the changes to professional medical society guidelines, a 2011 study reported no decline in the use of PCI. A number of media outlets covered the news, raising awareness among the public and questioning the continued reliance on procedures that were not shown to be effective.

Surely by now — years after additional research and attention to the issue — the use of angioplasty and stenting should have decreased. But unfortunately that is not the case, and it may be a matter of money. Recent cutbacks on healthcare revenue are being blamed for the overuse of stents — doctors make much more money through the $30,000 stent procedure than by spending time with the patient discussing the alternative: medication and lifestyle changes. In fact, in 2013 the Joint Commission and the American Medical Association Physician Consortium for Performance Improvement cited elective PCI on patients with stable coronary artery disease as one of the most overused medical procedures. And in 2017, a comprehensive investigation about overused medical procedures in The Atlantic pointed to the use of angiogram and stents as procedures that continue to be prescribed by physicians despite studies showing little benefit — and sometimes harm.

Some patients and doctors may also think that PCI helps to solve the “plumbing” problem of a blocked artery, but inflammation is a contributing factor and most ruptures occur at mild lesions. Misconceptions about the relationship between cardiovascular disease and narrowed arteries — with most patients erroneously expecting that a stent will reduce the chance of a future heart attack — may also be at the root of the overuse of the procedure. As many as a million patients in the U.S. may have been given stents they don’t need in the last decade. Unnecessary stents cost upwards of $2.4 billion a year to our healthcare system.

To raise awareness of this issue, the Parsemus Foundation has supported the publication of articles analyzing and discussing peer-reviewed studies on appropriate and inappropriate use of angioplasty and stenting. Our goal is to prevent patients and loved ones from facing unnecessary risks and in some cases debilitating medical expenses, without a clear expected benefit. Most patients undergo angioplasty because they believe it may save their life; if that is not the case, then they (and their doctors) deserve to know the full picture.

Media Coverage:

2011

• OAT Trial Had Little Impact on Clinical Practice, Forbes
• Guidelines Don’t Curb Unnecessary Treatment for Heart Attack Patients, Bloomberg
• Adherence to Angioplasty/Stent Guidelines Lacking: Study, U.S. News & World Report
• Heart Stents Still Overused, Despite Guidelines: Study, Huffington Post

2013

• Heart stents still overused, experts say, New York Times
• Deaths Linked to Cardiac Stents Rise as Overuse Seen, Bloomberg
• The Good, the Bad and the Ugly: Stents in the News, Forbes