Implant a Stent or not?

[mazenfs]

Hi,

I experienced angina last week and after blood tests taken in ER, the results were negative but the resident doctor explained it was boarder line negative and they needed to monitor me.  Several hours later and after plavix and other medications, another blood test was done and it showed positive blood enzymes and I was admitted.  A day later I did an angioplast that showed 80% blockage in my right artery due to what the doctor's believe is passed on by my dad.  I did not give the consent to the doctors to place a stent as I felt I needed a second opinion.

I am 40 years old, very fit and healthy and I felt perhaps I can beat this with diet and more exercise.

Just today, I had a second opinion.  The doctor viewed the CD and explained that I am in a stable condition but the stent would be a best option.  He recommended a drug - elluting stent although my case can withstand a bare-metal one.  He explained that me ever seeing him again for a stent would be less than 5% with a DES vs 15% - 20% with the other.  My heart rate, blood pressure and cholesterol levels were all excellent.

Doctor explained I can have the procedure on friday, out on saturday and at work on monday.  Back to the gym the monday after or so.

Plavix and aspirin for 6 months to one year and that's it.

I felt comfortable and well informed but...I still do not know if I should perform the procedure as I feel I can beat this with diet and exercise.

I truly need your advice...

M

[kenkeith]

http://www.************.com/about/silent_heart_attack.html

"Unlike during the regular heart attack, no chest pain typically occurs during the silent heart attack. This is a precarious situation, since strong pain in the chest is one of the most important signs of an incoming heart attack. This means that the early stages of a silent variant can very easily go unnoticed. Unfortunately, some 25 to 30 percent of all heart attacks are of this type.

It is important to remember that the signs of this type of heart attack are extremely gentle and delicate, and therefore more dangerous since it makes it very difficult for the doctor or the patients themselves to determine that a heart attack is incoming. Because of the fact that this condition is so difficult to notice, it has been dubbed “the silent killer”."

If you want the actual numbers, you can go to the AHA or American Medical Association.  I don't know if you are not able to do your own research, but in any event...You may want to contact those association regarding the details of the statistics that seems to cause you some doubt.  Or ask your doctor!:)

[kenkeith]

I was going to do a search of the archives for you (save time).  I have a very good memory :)  It seems to me if your doctor had given you the answer prior to your question to me, you would have included that VERY useful information and would not not have asked me the question!! There has been alot of headway with your understanding of collaterals, and I am proud of you:)

Ed, your method would not be possible!  Statistics NEVER rely on an accurate accounting of the entire subject population, nor an accurate accounting of the entire subgroup.  If there were an accurate total accounting there would be any need for statistical analysis .. there would be the perfect answer existing. Sooo as with any probable statistical analysis there are large samplings (should be) that  assume to be a fairly representation of the total population, then there are a sampling of individuals that have had silent ischemia, and/or silent heart attack (staying with the subject). You may have to research what is considered fair representation (complex) of the population because that is where you seem to be stuck.  

Also, to help you may want to google silent ischemia and silent heart attack. You will see richly pages of links.  I have done some research on the subject going back serveral years because I had had a silent heart attack and have collateral vessels. How the records are correlated, what are the records relied on, etc., would have to be answed by the statistician (it is his or her's work product to be evaluated and accepted by the experts) and don't hold the 26% as an absolute (ball park)..... Or you can do your own research (silent ischemia, silent heart attack), and I encourage you to do that if you are interested..

Another example, consider medical studies of one group with a placebo and another group with the medicine to be evaluated:  When the results of the study are determined the results are applied and assumed the regimen or lack thereof to be applicable to the afflicted population. It is not possible to give an entire population a placebo, and everyone of another group the medication... so there is a reliance on the outcome of the study group (samplings).  Hope this helps.

[ed34]

"Changing subject: You are using my response to you several months ago........"

Well actually no, I was talking about a discussion I've recently had with a cardiologist who was going over my Wifes echo scan results. He stated it is not unknown to have a patient wheeled into the angio suite and suddenly all discomforts and problems suddenly stop. He also said how reverse flow through a section of an artery is very common with collaterals feeding into it.

"The percentage of an unknown"

This isn't very clear at all. Are you saying we take all the known people with CAD in the world, then take another group of all the people in the world who have CAD but are unaware of it, they will be a quantity of 26% of the knowns? even though we have no idea how many there are?

[kenkeith]

QUOTE:"Well, not quite. Collaterals can open instantaneously according to some cardiologists, especially during a heart attack".

Changing subject: You are using my response to you several months ago whether there can be instantaneously collateral vessel flow in an acute episode of blockage?  I answered affirmately and is possible....and now you are making an exception to my present answer on this thread!  Yes, there are instances with an acute blockage, but on this thread the discussion relates to having collateral vessels develop and functioning adequately over a period of time (gradually)... in all likelihood there would be no symptoms of angina, etc.

QUOTE: Do you have a source for the ideas behind calculating the 26%, because I fail to see how this can be anything but a wild guess?  I would think the top reason most people don't realise they have disease is simply because the blockages aren't sufficient to give any symptoms yet". QUOTE: " I would think the top reason most people don't realise they have disease is simply because the blockages aren't sufficient to give any symptoms yet"

>>>>> It is not a wild guess.  The percentage of an unknown and significant heart condition is an extrapolation from the statistics of having silent ischemia, and/or silent heart attack.  Blockage and heart attack can be without symptoms.  My first symptoms of an ischemic heart attack was congested heart failure.  

[ed34]

"Collateral vessel develop very slowly and as needed based on the gradual reduction of blood flow through occluding vessels"

Well, not quite. Collaterals can open instantaneously according to some cardiologists, especially during a heart attack. There have been numerous cases where total blockage has caused typical heart attack pains, which have dissipated quite rapidly where collaterals have immediately opened.
I believe that almost all those patients will be on some kind of beta blocker, and we mustn't forget the massive effect that medication has. If I stop my beta blocker, I would estimate my angina at least doubles. So while things may look terrific on the surface, in reality they are not so brilliant. Wasn't your Heart attack many years ago? and yet don't you take nitrates to help with exercise? So, obviously native vessels are better.
If you are on a beta blocker, then this will obviously feel a lot worse.
Do you have a source for the ideas behind calculating the 26%, because I fail to see how this can be anything but a wild guess? I would think the top reason most people don't realise they have disease is simply because the blockages aren't sufficient to give any symptoms yet.

[kenkeith]

QUOTE "Your heart is meant to have blood supplied through the native vessels and almost all people with collaterals have to take medication so they can withstand exertion and exercise".

That may be true for some but hardly an issue to hang your hat on.  Collateral vessel develop very slowly and as needed based on the gradual reduction of blood flow through occluding vessels.  I contend the development is in sync otherwise there would be angina pectoris and if there is angina that indicates there is not very good development of collaterals. There are many individuals within the CAD heart population that don't know they have any problems (estimated to be about 26%).

[ed34]

I've tried to explain this to you several times. The status quo is to get your disease under control. You have to work hard at this to achieve it, like diet, regular exercise, blood pressure control and cholesterol management. On top of this, you have to analyse your whole life, establishing any areas of high stress and eliminate them. No intervention is going to work unless you get the disease progression under control. Doing nothing will accomplish nothing either because the disease will simply get worse, making you very ill, or killing you. Once your disease is under control, then bypass surgery and stents will make very positive contributions to your life. Your heart is meant to have blood supplied through the native vessels and almost all people with collaterals have to take medication so they can withstand exertion and exercise. This shows the heart is not working properly, else it wouldn't rely on drugs such as beta blockers or nitrates. It highlights a flaw.
My cardiologist told me it's shocking how many people don't take lifestyle changes seriously enough. They think because they have a stent, they will never suffer disease again. He also said it's amazing how many he has caught still smoking cigarettes.
I took the changes seriously, very seriously. I had disease (99%) in my circumflex in feb 07. This was stented. According to statistics, I had around 20% chance of restenosis in the first 6 months. This didn't happen. After 1 year, still no disease. Now after nearly three years, there is still no sign of any disease. Next year I will be classed at 1% for restonisis. The 5 stents put down my LAD have not diseased after more than a year. I seem to dodge that 20% every time, but why?  because I make an effort.
I never see in research where it states how many still smoke. Of course it doesn't, the patients lie, they are not going to admit such stupidity. If you walk through any hospital in the UK, you will see many patients outside having a cigarette. Some of them WILL be from the cardiac unit.

[nagrajjain]

You can go through my case for guidance. After angiography looking into the extent of blockages I was advised bypass ruling out stents. I was told if not then i may have third heart attack any time and may result in death.I asked if doctor can give me guarantee of life atleast for one year then I will go for bypass. Doctor did not do that I am still living for three months on medicines. Even after spending good amount there is no guarantee.Even after going through all treachories of bypass there is no guarantee then why to go for? You have to take your own decesions as risks are involved. Nobody else will take risk even after payments.You can contact me if you please.

[kenkeith]

QUOTE: "I would have the stent any day.  I would rather do that then not do anything at all".

>>>>>>  But there are options and choice...true, not do anything is not very good option!.

QUOTE: im 47 have had 3 HA i have lost count of how many stents i have but let me tell you,you do not want to experance a HA,The docters know what there talking about when they say u need a stent,your life is gonna change! But you will still have one if u do what they tell u.Not having this done is certen death,it will kill you!!!!!!

>>>>If you have had 3 heart attacks, then all the prior intervention with stent implants wasn't  providing much protection and that is expected.  Stents will not preclude you or anyone else from subsequent heart events.  With heredity aside, to prevent heart attacks from coronary heart disease requires proper diet, exercise, heart friendly lifestyle, etc.  As the previous poster states doing nothing is not a very good option!.

I  had a heart attack about 7 years ago, and today and since the HA I have a totally (100%) occluded left descending left artery, 70% blockage of another artery. My heart attack was silent (no chest pain, etc.), and apparently you had severe chest pains.  That is not always a heart attack, but may or may not require rescue PCI (stent implant).  Also, with acute heart attack may or may not require salvage PCI (stent implant). Almost everyone would agree with that!

Thanks for sharing your experience.  Take care

[ChatterAlly]

I would have the stent any day.  I would rather do that then not do anything at all.

[drnail]

im 47 have had 3 HA i have lost count of how many stents i have but let me tell you,you do not want to experance a HA,The docters know what there talking about when they say u need a stent,your life is gonna change! But you will still have one if u do what they tell u.Not having this done is certen death,it will kill you!!!!!!

[kenkeith]

Diet, exercise, or medication will not reverse coronary artery disease (CAD), but can slow or stop any progression. But who knows, in a few years it may be possible to reverse.
If you have unstable angina, that is chest pain with or without exertion, usually the best option is a stent.

Study for stent v. medication the "statistics are after an average follow-up of four and a half years, the two groups were remarkably similar. Getting angioplasty and a stent to hold open a narrowed artery didn’t offer any extra protection against a heart attack, stroke, hospitalization for acute coronary syndrome (the umbrella for heart attack and unstable angina), or premature death.

The only big differences were in freedom from angina and the need for follow-up procedures. After one year, 66% of those who underwent angioplasty were free from angina, compared with 58% of those on medical therapy. By five years, though, there was no difference, with about 73% of both groups reporting no angina.

In follow-up procedures, about 20% of those who initially underwent angioplasty needed a repeat angioplasty or bypass surgery, while 31% of those who started on medical therapy eventually needed to have angioplasty or bypass surgery. Better medication is evolving so that may reduce the need for angioplasty.  I have been on medication for going on 7 years with a totally blocked LAD (collateral vessels provides sufficient blood to deficit areas) and 70% blocked and have no problems with my medication.  I do take a nitrate prior to exercise workout, and with a stent there may or may not be a need for the medication (nitrate).

I agree with the idea to go with diet, exercise to improve your cardiovascular system.  No need for cholesterol management.  

Thanks for sharing, and if you have any followup questions you are welcome to respond.  Take care.

[Flycaster305]

You are going to get a lot of response to your question with different points of view.

The stent procedure is now minimally invasive, there are very few complications when done by competent physicians.  I have four DES stents, four bare metal.  I've had no restinosis.  With an 80% blockage, I would certainly have the stent inserted.  

If you have excellent cholesterol levels, a tight diet control probably isn't a big factor in your case unless you are diabetic.  Exercise can sometimes develop collateral arteries to form that take the pressure off the blocked artery... but not always.  In my case, exercise helped develop collaterals along with other drugs, I think, but it took a long, long time.

I'm a volunteer at a critical care CVCU hospital and I sure hear a lot of 'shoulda/woulda' comments from patients and loved ones.  Also, your commitment to diet and exercise has to be a daily discipline.  I'd get the stent, and commit to the healthy lifestyle.  You have a lot at stake with an 80% blockage.  Keep us informed.  

[ed34]

There is not a natural way that you can remove the blockage. Nothing in the body will break down the 'mass' and remove it. It was actually your immune systems attempt at removing the initial material that caused the blockage. There are two things which you can hope for, 1. that the blockage doesn't get any worse, 2. that you develop collateral vessels to feed heart muscle if the blockage does worsen. However, none of those options remove the risk factor you currently have. A blockage of 80% could rupture at any time and cause a severe heart attack or even death. The problem is, nobody can tell you when this rupture will occur, if at all. It is how people have heart attacks and we know there are millions who do and it's the biggest killer in some countries. Some people have had blockages on the border line for many years, or total blockages and got away with it. Personally I think this is luck and a very big gamble. If you have no symptoms then it's likely your heart tissue is getting enough oxygen, BUT this doesn't remove the fact that there is a huge risk you could find yourself fighting for your life.
Your Cardiologist is offering this option because he knows the risks that exists, statistics of heart attacks and deaths tell him this plainly in black and white.
Knowing this, I hope you really think about it and make the right decision.