Stents or?: Has there been any research... - British Heart Fou...

British Heart Foundation

26,693 members17,532 posts

Stents or?

Myaphrodisiac profile image
Myaphrodisiac

Has there been any research done over whether it’s ‘better’ to have stents or bypasses? Is there a difference longer term to do with further heart attacks and or longevity?

55 Replies
Milkfairy profile image
MilkfairyHeart Star

Hello,

The Ischemia Trial published recently came to this conclusion.

'The ISCHEMIA trial showed that an invasive approach to patients with moderate to severe ischemia did not significantly reduce a composite endpoint of myocardial infarction (MI), cardiovascular (CV) death, hospitalization for unstable angina or heart failure, and cardiac arrest compared with a conservative medical strategy—without initial angiography. The hard endpoints of MI, CV death, and all-cause death also did not differ between the treatment arms.'

Cardiologists are busy debating the results it wasn't what they expected.

You need to talk to your Cardiologist to make a decision about what's best for you.

medscape.com/viewarticle/92...

Pollypuss profile image
Pollypuss in reply to Milkfairy

I wonder how many people were considered in this trial and how many variants .

Milkfairy profile image
MilkfairyHeart Star in reply to Pollypuss

It was a very large multi national trial over a long period of time.

acc.org/latest-in-cardiolog...

Thank you 🙏 xx

The decision to have a stent or bypass is not straight forward!, in my case the there was no option but to have a bypass due to the severity of damage to my LAD artery. It was impossible to apply a stent because of the damage, I was hoping prior to tests and was initially told a stent would sort it, I would have preferred a stent, a lot less to go through. You are basically clearing a blocked pipe, stents are quicker and faster recovery. Take care Stephen

Thank you 🙏 xx

I was also in a position of no choice but a bypass. Sudden heart attack and emergency resulted in having one stent fitted during the procedure discovered more areas required attention but deemed in areas to dangerous to attempt stents. So a triple bypass six weeks later

Gil

Thank you 🙏 xx

Recent Trial aside, I think it’s difficult to say due to different variables. Since 2012 I have had 8 stents, in that time I know others who have had one or two stents and not had any further issues, that said I would consider myself fitter than them (relatively speaking), last November I ended up undergoing a quad bypass. Managing my situation with medication and no intervention was also tabled by my cardiologist as an option, however was least best for me putting off inevitable. Given the differing nature of Ischaemic disease it impacts each of us differently. I think as has already been said best discuss with your cardiologist to decide what is best for you in your circumstances, only you can make that decision. Hope that helps.

Thank you 🙏 xx

Hi all, regarding the issue of stents if I may ask a question. On May 2017 I went into cardiac arrest in A&E waiting area while waiting to be seen. After being shocked & resused I was rushed to another hospital where the blockage was cleared. I was told that normally a stent would now be inserted into the unblocked area but in my case the artery was too narrow to allow any stent to be inserted in this area. I was told that with medication hopefully the area will remain open but no guarantees. This worries me a great deal as I feel the area could close again at any time. Has this situation happened to anyone else?

I dug into this question quite deeply a year or so ago, the answers I found surprised me.

Firstly regarding stents, for those patients who have stents fitted when they've been hospitalised for a heart attack, they are clearly life savers. The difference between the heart attack survival rate in the pre stenting era and now is chalk and cheese, and it's stents that account for most of that improvement.

However, for stents fitted in elective surgery (ie in a non emergency situation, say as a response to stable angina) there's virtually no evidence that stenting delivers any additional life expectancy. There's a growing debate in medical circles about why stents are fitted at all except for heart attack emergency treatment or to open up very specific blockages and relieve disabling angina. The suspicion is that, in the same way that if the only tool you have is a hammer then every problem becomes a nail, so with stents they've become over used.

There's a bit more evidence that by pass surgery yields additional life expectancy, but it wasn't a huge amount and was quite a bit less than I'd expected (or, as a bypass patient, hoped for!).

Talking to my cardiologist about all this he emphasised that neither stents nor bypass surgery actually cure our heart disease (atherosclerosis). The best they can do is to give us a second chance, a chance for a combination of serious life style changes and medication to slow down the progress of our disease.

The bottom line seems to be that for atherosclerosis patients our future life expectancy is more likely to be driven by our own life style efforts and diligence in taking our medication, than due to any surgery we've already been given. That surgery may have gotten us through to today, but it won't help much in terms of seeing in tomorrow.

My father died of an heart attack aged 64 , 29 years ago,exactly the same diagnosis that I have, no stent available, limited medications, and limited investigation into what the problems was. How long he may have lived if the treatments where available those days we won’t know but probably a good few years. I have never smoked, slim build, super fit, but still fell foul of heart disease, so the point I am making , regardless of lifestyle some illnesses are unfortunately inevitable. Take care Stephen

Possibly Steven sometimes illness is inevitable but I like you, am slim and fit but have heart disease.Rather than inevitable though, I believe that you, like me, simply do not understand the cause of your disease.

Being slim and fit is no guarantee of health and something is causing the lining of your arteries to become imflammed and damaged.

Do you have high blood pressure, stress, small dense highly atherogenic non hdl cholesterol, high Lpa, impaired insulin resistance etc, the list goes on.

Heart disease is not inevitable, you, me and worrying lots of cardiologists simply don't understand all the causes yet.

That's not what Stephen said..he said that unfortunately some illnesses are inevitable regardless of how well we live.im guessing by that he means some heart diseases are kinda passed down from our ancestors.which is why the cardiologists always ask that question..."is there any history of heart disease in your family??"

sherwood123 profile image
sherwood123 in reply to Debtyd

Hello , a lot of illness are unfortunately passed down from parents, “Hereditary”, Not just heart problems, some woman have to have a mastectomy to prevent , in some cases to fatality . There is some research into gene therapy, to eliminate these genes, but until the time comes when parents are scanned for all major illnesses, it will continue, choose what your lifestyle is. Take care Stephen

Debtyd profile image
Debtyd in reply to sherwood123

??I know that's what I was saying....i was agreeing with you in your defence lol xdebx

sherwood123 profile image
sherwood123 in reply to Debtyd

When post my views on here , I am not disagreeing or agreeing with anyone, we all have our own ideas right or wrong. Obviously we all have a problem in one form or another, I wish we all did not. One day heart disease may be something you read in history books. You take care Xxx

My mother had bypass surgery 40 years ago at the age of 49. She lived for another 25 years. She died of cancer. I am 60 and had exactly the same surgery my mother had (not much has changed in the procedure in 40 years). If that extends my live by another 25 years, I will be very happy.

Wow, weird. My dad was 64 when he died of a heart attack 29 years ago. Almost no treatment provided. I, too, am a fit, slim, nonsmoker. I went through so many tests to confirm my Coronary Artery Disease and blockages in two major arteries. I am being treated with meds, because I am already living a very healthy lifestyle. I was floored, to say the least, with the diagnosis. You are correct, genetics and heredity unfortunately can make CAD inevitable. No stent, for now, as long as we can control angina with meds.

If you can get tested every few years, I had a scan after he died, everything perfect. Times rolls on and we live our life, but unknowingly the disease is creeping upon us, my Daughter and son have both had tests and all is fine. But both are aware complacency could be there downfall, they will be getting checked as they get older, even if they have to pay. Take care. Stephen

Thanks! I won’t roll over for this disease. I intend to stay active and stay in it. Meds are allowing me to stay active. I’m keeping my kids aware, too. Being proactive is important. You take care, as well. Cindy

Is there anything more depressing than someone making a point of the fact that the current available treatment for heart disease is a waste of time, thanks for that.Luckily your wrong, even as long ago as 2003 the 20 year survival rate post CABG was 40%

I'm sure these people would be dead without the surgery so in my opinion the treatment works and if I ever need it I will be very grateful to have it.

Thank you for that, my husband had a quintuple bypass 2 years ago and I hope to see old age with him by my side (some might say we are already there!) He had no choice by the way and was previously fit and well with no knowledge what was going on until a mild attack revealed the damage.

Hi, there are people on these forums, like Milk Fairy, who know far more than I do about these things but from the research I have done I think that you and your husband should be very confident about his future 👍I think that everything should be well and truly healed by now and if he has had no problems by now I think most people will be OK for a good few years yet. 😊

Milkfairy profile image
MilkfairyHeart Star in reply to fergusthegreat

That is not how I read Chappychap reply.It's not just about survival it's about quality of life too.

Some types of myocardial ischaemia can only be treated by medication. Heart disease involves more than blocked arteries.

The research is suggesting that stents and surgery aren't necessarily appropriate for all presentations of angina.

The Ischemia trial results were a surprise to the Cardiologists and they are busy debating the findings too.

Diet, lifestyle etc are important.

acc.org/latest-in-cardiolog...

Thanks for the link, it makes interesting reading.I have read the results of several trials regarding heart disease.

Do you know why they normally list the primary outcome as all cause mortality?

Surely if you want to evaluate whether a treatment for heart disease is effective or not you should list cardiac mortality.

It does not seem relevant if someone gets run over or dies from cancer etc?

Agreed and the same argument applies to an awful lot of ‘Covid deaths’. Why is is we seem incapable of assigning the true cause of death according to circumstances?

Milkfairy profile image
MilkfairyHeart Star in reply to fergusthegreat

You make an interesting comment about all cause mortality. Patients often have a different perspective about research outcomes.

Patients often value quality of life as well as quantity. This is not always acknowledged well in clinical research studies.

You may be interested in this article written by leading Cardiologists in the UK about the study.

academic.oup.com/cardiovasc...

Thanks for this 👍

I know people in their nineties who have had stenta! Of course you have to change your life style and take you meds but I see no reason why you wouldnt live to what would be a normal age for anyone. Unless you die of something else. My cardiologist said my problem was minor and that my heart itself was in perfect condition.

You've misunderstood what I wrote. I was clear that stents and bypass surgery can save the lives of heart attack victims, and they can also deliver material improvements in quality of life.

However, there's zero evidence that stents extend life expectancy by preventing future heart attacks.

In the UK there was a 2017 study published in The Lancet, this followed on from a 2013 study by the American Medical Association. Both of these studies reached the same conclusion, stenting does not prevent future heart attacks and consequently doesn't enhance future longevity. Much the same conclusion is in the more recent ISCHEMIA trial that Milkfairy linked to.

If you choose to interpret these as "depressing" then that's your prerogative. Personally I don't. For me the real conclusion is that surgical interventions may save my life in an emergency, and a bypass operation delivered me an absolutely transformational improvement in life quality for which I'm very grateful. But they're not what I'm really relying on for a long and active life ahead. For that I'm putting my faith in medication and life style changes.

I'm realistic that the biggest single risk factor is age itself, which of course none of us can do anything about, but that still leaves plenty of improvements that I can, and do, take responsibility for.

mike2002 profile image
mike2002 in reply to Chappychap

Crystal clear.

Milkfairy profile image
MilkfairyHeart Star in reply to Chappychap

Good points well made as ever

Surely if you have partially blocked arteries it is better to have stents fitted than wait for a heart attack to happen or to have a bypass, which is major surgery so carries risks of itself? You seem to be saying stents should only be used in an emergency situation. I had stents in 2 arteries a couple of years ago and the difference is incredible.

Milkfairy profile image
MilkfairyHeart Star in reply to tiredwalker

Read the Ischemia Trial findings I posted above.

You can also live with Ischaemia non obstructive coronary arteries INOCA which increases your chances of a heart attack, stroke or heart failure without a blockage insight.

The only treatment option is medication for Microvascular dysfunction and vasospastic angina.

Stents and surgery save lives for acute situations.

The debate is whether these interventions are appropriate for stable chronic angina.

That's not what I'm saying Tiredwalker, I pointed to the value of stents "to open up very specific blockages and relieve disabling angina.". Reading between the lines of your reply that may well be you, and if so I'm delighted to hear how well you've responded to treatment, long may it continue! But there is a difference between improving quality of life and improving length of life. I had bypass surgery and it was absolutely transformational, I feel twenty years younger. If I knew I were to die tomorrow I'd still judge that surgery a complete success.

I suspect there's quite a lot of misunderstanding about the true nature of atherosclerosis (large vessel heart disease) and that may be at the root of your question. Phrases like "furring up" and "hardening arteries" obscure as much as they illuminate.

No analogy will ever be perfect, but let me suggest an analogy that may be a bit closer to reality. Think of heart disease as like acne in the arteries. If one of those "spots" bursts then the liquid contents will immediately solidify upon contact with blood. In the great majority of cases (not all, but the great majority) that solid lump will remain attached to the parent "spot". In other words it's unlikely to whizz along the artery and cause a blockage in a constriction elsewhere. If it blocks the artery then you experience a heart attack, a quickly applied stent at that specific location can save your life. Score one for stents!

Likewise a "spot" that has swollen to the point where it's almost blocking the artery may cause severe angina. Again, a stent may relive the symptoms. Score two for stents!

But the reality is that there will be many, many "spots", too many to stent, and as with acne new ones are forming all the time. That's why there's no evidence for elective stenting increasing life expectancy.

There's another twist to this. Some people have "spots" that are very liquid and prone to burst. Other people tend to grow harder "spots", or spots that begin liquid but quickly calcify into stable, harder spots. This analogy (which came from my cardiologist by the way) helps explain why some people suffer heart attacks relatively young and with relatively low levels of arterial blockages, and with absolutely no angina symptoms. While other people can suffer severe blockages, with disabling angina, but with no or perhaps only a solitary heart attack. It's because they have very different types of spot, some have hard spots that refuse to "pop", while others have more liquid spots that pop quickly and easily.

The real key is for each of us to find the medication/life style balance that stops or slows the formation of those spots, or if they do form then turns them into stable, hard spots as quickly as possible rather than remaining as liquid, angry spots.

That's a very good description of atherosclerosis. Once you have the disease it's generally in a lot of places not just one.I'm realistic enough to know that the stent I had in my Lad will not do anything to stop the 30% stenosis that I have in my Rca from giving me a heart attack, only medication and lifestyle changes to address all my modifiable risk factors can hopefully do this.

However, I think that this is where the Ischemia trial results are misleading as they did not record the location of the incidents. I bet most of heart attacks, repeat revasculations etc we're in non culprit lesions and not in the original ones that received a stent.

If this was the case then I think it shows that stenting does offer a benefit but only in the treated lesions.

My view is backed up by the results of the 2019 COMPLETE trial which showed that complete revascularization of all lesions was superior and offered a survival benefit when compared to only stenting the culprit lesion.

Well thanks for that, I felt great till I read it.

COYW profile image
COYW in reply to Chappychap

Outstanding summing up, well done 👍

Pollypuss profile image
Pollypuss in reply to Chappychap

Absolutely. How you live after your bypass/stent is very important. Forget junk food, smoking ,weight gain . Exercise is so important. A healthy life style can become a habit. I wonder if these considerations were taken during the trial. I was in hospital with someone who had been smoking since they were a child and was often going out to have a cigarette prior to their open hear surgery for instance.

Last August I had a STEMI. A heart attack which resulted in the complete blockage of the Right coronary artery. When they looked via the angiogram/angioplasty they found that the artery was ectatic. That means apparently that it is not uniform in diameter, and not smooth in end to end shape. They could not stent.

So they did their best to clear it via the angioplasty and anticoagulants.

The following day they tried again, and managed to get sluggish blood flow through the artery.

Turns out you can survive with a partly blocked coronary artery. The heart muscle it feeds is of course dead, but I suspect that by the time I had been taken into the cath. lab, that would have been the case anyway i.e. the RCA is not relevant, so a stent would not help.

At least that's what the cardiologist says. But I do get what I assume is angina (never had it before MI), and I am assured that the RCA is the culprit. So it seems to me that the RCA is at least doing something useful. So it also begs the question "does stenting help in all cases?".

In my case nobody seems keen to think about CABG. I guess for the same reasons. It would also be very technically difficult. So the risk/reward ratio is poor.

If anyone has any ideas or has had the same sort of issue I would be very interested

Notdead profile image
Notdead in reply to Chappychap

I have been searching for answers since my ha 9 days ago , thank you !! You have helped me a great deal in what you have just said

So I guess there are a number of reasons for stents rather than bypass - assuming the outcomes are about equal which I assume is the case from the study.

1) risk of surgery. If stents or bypass have the same effect then most people would see that having a procedure without need for general anaesthetic and open heart surgery would be preferable, less risk of death during the procedure and immediately afterwards. Potentially fewer side effects like strokes and brain fog. Also considerably easier on the patient. 4 days after having 3 stents I'm pretty much back to normal activity levels.

2) Cost. No getting away from this one, putting stents in is cheaper than open heart surgery. Less hospital and recovery time and back to work (for those who do) is better for the economy...

3) If there's a problem with the stents over time then having them doesn't prevent future bypass surgery. It appears that restenting is possible too with advances in technology. While I now have 6, it appears the record is 39 for a guy in India.

Now that's a world record to beat 😂😂

Debtyd profile image
Debtyd in reply to firstlight40

I had 2stents in the lad as on a routine angiogram following all other methods of investigations and given the all clear, they found a total occlusion...100% and a partial blockage in another artery{top of my head I can't remember which is which but it's the middle one????} I was told there and then that if they couldn't unblock it enough then I wouldn't be able to have stents and I would've had to stay in for a bypass.so I think that the less invasive it is then it's less traumatic for your body.also it doesn't matter so much to me which I had,I am just so grateful that they found what they did when they did and I feel so lucky that i didnt suffer a heart attack as a lot of you guys have done.i have to under go the procedure again in 3 weeks as my quality of life is still a little slow due to similar symptoms as I had prior to stents in october has not changed at all....so I'm merely hoping that my quality of life will improve to accompany the hard work put in by surgeon and his team..i live an already healthy ish lifestyle and I'm trying to improve in areas like exercise which is just not happening atm..i think bypass or stents depends on many different factors.you don't really get to choose.xDebx

I hunted everywhere to help my wife avoid bypass surgery. Stenting was not an option do to position and extent of artery damage. The ISCHEMIA trial gave me a glimmer of hope but the extent of arterial blockage studied was low. Can't remember the extent studied but maybe anything over 50% blockage meant stent or bypass was necessary. Best trust in your cardiologist or surgeon for advice.

If you mean stents vs. bypass, bypasses are generally done now more as a lifesaving measure, from what I’ve read. If you mean stents vs lifestyle and medication, that’s the real gray area. I had 90% LAD blockage with no angina, but still had 2 stents fitted. I think there are a fair number of cardiologists, especially in the US, who might not have done that, given what the study found. My brother also has CAD, but he is in the US, so his cardiologist put him on a large dose of Crestor and advised a low cholesterol diet.

Bottom line, it’s not cut and dried at all. I have not bounced back from the stents the way I wanted to, but in the long run if it gets me a few more years I’m ok with that...

I had a CABGx4 in January this year. They could stent 3 but not the LAD because of calcification. The cardiologist said that bypass was considered to be gold standard so bypassed all and that they in turn could be stented if required. Do not worry about longevity of either , if you exercise and look after your diet plus take your meds you will have many many years ahead of you. My neighbour had his CABGx4 @ 62, he is now 84, plays his golf and enjoys a few pints still!

I’m not sure if the two stents I have are there to prolong my life but what they do is give me a better quality of life. The cardiologist asked me what I expected from the angioplasty and I said ‘ I don’t want to feel like a really old person’ - my atypical angina was causing SOBE and considerably impacted by ability to walk let alone more strenuous exercise. They never promised me that it would reduce my risk of HA. They said that was up to me particularly as I have a very high lp(a) and was pre diabetic. They said my lifestyle would make the difference- exercise, weight loss, reducing stress, getting my cholesterol down via lifestyle and meds. I’ve now reversed the diabetes, lost some weight and exercise regularly. I do now feel it’s up to me whether I choose to remain healthy. I thought I was doing enough before but the lp(a) which was the snake in the grass has meant a bit more of an effort.

My hubby had a HA back in 2007, aged 57. He had a stent inserted at that point and the difference was instant! He was out on a variety of medication and also diagnosed with T2 diabetes. He was told he may need another stent in years to come. He continued working and didn’t take much care of himself.Roll forward to 2017 he was beginning to feel ‘not right’ was easily tired and generally slowing down.

22nd March 2018 he woke in the morning with a ‘sore heart’ and not feeling good at all. He had an appointment for a blood test that day so we went to it. He told them how he felt and the nurse did a few tests and then spoke to the doctor, who sent us to the hospital for a ‘precautionary blood test’! He was kept in, given loads of tests and attempts were made to insert more stents. He was given two choices - stay in and we will do a triple bypass in the next month or go home and onto a waiting list for 3-6 months. He stayed in, had a quad bypass about 8 days later (brought forward by 5 days) and came home after a month!

His stent had lasted 10 years and was still ok but other arteries had ‘broken down’. The policy here seems to be to stent as a first option and OHS as a second.

Everyone’s case is different, there’s a lot of factors for a cardiologist to consider when deciding stents or OHS even in an emergency situation. I had no symptoms and 1 episode of angina, angiogram done and 95-99% blockage found and couldn’t be stented so OHS a few weeks later of a double bypass in Sept 2020, i was great for 2 weeks then had post op complications as one of the grafts failed and i was extremely poorly for 7 weeks with daily heart attacks before the problem was found, eventually i had emergency op to have stents put into the failed graft and got instant relief and had a further routine stent a few weeks ago. I am lucky and grateful to be alive, everyday is a bonus, and a lifestyle change isn’t so bad in the grand scheme of things

Stay safe and well and have faith in your cardiologist x

Here's a link to the results of the COMPLETE trial that I was discussing earlier if anyone is interested.

acc.org/latest-in-cardiolog...

Hi. Following along after Milkfairy's excellent provision of information, just adding to the general thread . . After all the usual tests, I was booked in for an elective quadruple bypass. I thought my world had ended, I so much hoped that stents and medication would at least be an option.I spent weeks in sheer anxiety, waiting for an appointment with the Surgeon. Crazy or not, I even considered the ultimate sin, I was that distressed, and too ashamed to tell anybody, as I could guess how they would respond.

Day of appointment came around, by this stage I was prepared to go down on my knees and beg, if that's what it took, for the Surgeon to find an alternative to QBP surgery.

Long story short, my guardian angels must of prevailed, as Surgeon told me that because of all my other exsisting severe medical conditions, including having had a stroke 6 months ago, there was no way he was going to do a QBP on me.

He said the odds were way too high and I wouldn't make it off the operating table and he was very sorry. SORRY ?

I was ECSTATIC!!! He went on to propose that he intended to put in 4 stents under GA (constant observation) and an overnight stay for observation due to my medical history.

Today, more than happy living with my stents and bucketfuls of medications, and very glad that I didn't give up on life, but I can totally understand how people do get to that point, that level of distress and despair, what ever the causal event.

Whoever you aspire to as being your spiritual leader, keep the faith, as they sure do work in mysterious ways.

Keep well and stay safe 😷😷😷

I have to say that I find the whole issue of the criteria used by the NHS for stenting or by-passing to be something of a mystery.More to the point - communication as to the reasons behind the decision is lacking.

You may also like...