to stent or not to stent - basis?

[p1954]

Does anyone here have a study reference which compares outcomes for patients similar to me - 90% blockage in one cardiac artery, where pateints did not undergo stenting, but may have used drugs and lifestyle changes?  

I am still trying to sort out the rationale for stenting as, on hindsight,  I now realize how uninfomed I was on the morning of the angiogram and stent.    Am trying to reach the interventional cardiologist and go back over the pros and cons and his decision process.

[ed34]

Every time I've had stents (10 now) Ive felt immediate benefits from the procedure. How long have you been on your cholesterol medication? Statins can cause those symptoms and you should consult your Doctor.

[judy248]

had a stent put in 3 months ago,the fatigue is over welming, i cant work, im limited to doing anything. the most i can be is like 3 hres per day, they tell u to excersise. i walk 30 minutes every other day than im totallt exhausted has this happened to ayone else im on plavix,aspirin low dose blood pressure and cholestral

[Occupant]

I look at it a little different - high risk means it you haven't developed any collaterals and if the RCA occludes to 100% you're going to have a heart attack. Whether or not you are going to die depends on a lot of things. Livestyle changes and diets are not going to remove the existing blockage. A cardiologist once told me, if you can get your LDL below 50 you might be able to reduce the existing plaque. The good thing is, in your case, that you don't have any angina - meaning, you probably have developed collaterals. So, the question is how much are you going to bet on that and how long does it take for the RCA to completely be blocked?

[p1954]

Thanks for your thoughtful reply....I am not actually claiming that the wrong thing was done.. What I am trying to do is understand the basis for stenting.   If as you wrote,   blockage about 70% is high risk and warrants stenting then that must have data to support it.  I have seen a lot of data to suppoort there being problems with stenting.  what does high risk mean and for what kind of patient profile?  Compared to what?  

I had a heart attack after a long stressful period in my life and during a very emotional night.  from I can tell of the diagonstic reports the stented artery had nothing to do with that.  I was not suffering from chronic chests pains or shortness of breath leading into this.

  It just seemed that after the testing, including the angiogram, the stenting cold have waited until I had a chance to rest and get clearheaded and better informed and have discusions with a medical cardiologist as well as the interventional cardiogist and review some of the literature.  a few weeks and a couple of Q&A sessions would have made me much more informed about the risks, and options, if any..

I think it is legitimate to want to know ahead of time, when possible, what study outcomes indicate for certain patient types for any given procedure, or alternatives, or what the doctor uses to inform himself in his own decision process.    

[ed34]

It has nothing to do with references, statistics, studies or trials. At the end of the day it's about YOU, the PATIENT. If you go to hospital with chest pain and after tests they discover you have a 90% blockage, then they will want to stent this because of one very good reason. It isn't because the blockage could increase to 100%, it isn't because it gives them more practice. It's because anything over 70% is classed as high risk for rupture. If the blockage ruptures, you are at very high risk indeed for death. Even if you have no pain, medication is helping enough, this is still basically a time bomb waiting to go off. 100% blockages are often left, because these are far less likely to rupture. They are compact and held together from all around the lining, whereas a smaller blockage is not held closed by anything at all.
What happens when a rupture occurs? The harder plaque case which is like a cap, a drain cover, comes loose, it fractures and breaks free. It then travels down your coronary artery until it reaches a branch too small for it to pass and it blocks the vessel, it lodges tight. It could get to the brain and cause a stroke. It could get into ANY body artery and stop blood reaching a section of ANY organ. Then the nasty soft stuff in the artery is allowed to burst free. With no hard cap holding it at bay, a substantial amount of soft plaque breaks free and travels down the artery. This is made up from lots of different types of dead cells, including macrophages which have died and left pure fat. This will also find a smaller vessel to block. So, that's two problems from one rupture, but there's still the third problem to come. You now have what appears to the body as a damaged artery. It has a gaping hole in the lining, one which requires repair. Your body believes this artery is leaking, even though it isn't, and your body wants to stop blood escaping. So you now see your platelets in that area clump together and form a clot. This will now stop blood flowing any further down that coronary artery, causing a heart attack. That's why we take aspirin, to prevent this final stage. This stage is normally the killer because it can occur anywhere in an artery, top, bottom or middle. When the ruptures occur, the debris mostly blocks smaller vessels, or distal parts of major ones which are less likely to cause death. You can still develop a clot when a stent is inserted, which is why antiplatelet medication is prescribed for life. You could also grow scar tissue through  the mesh of a stent, causing it to block, hence the reason for the developed drug eluting stent, developed to inhibit this.
Back to statistic. It really isn't clear cut about how to study such things. It makes a big difference with details such as composition type of the blockage, the location of the blockage, if any other disease is in the close vicinity etc etc. Lots of things to consider. It also depends on their lifestyles, their emotional stress levels and many other factors. Virtually every year they seem to discover a new risk factor, so studies which have been running 10 years are obsolete because they never included this new information. Genes are now believed to play a large role, at least two genes have been identified. At the moment, you can only take each individual case. I remember in 2007 when I was going to have stents used in my left artery. A cardiac surgeon overruled my cardiologist, saying bypass was the best option and I would have a fantastic future, a normal quality of life until I was in my 80's or 90's. He was some salesman. I had the triple bypass because I believed his speech. Just three months later I was walking home from the local store and I collapsed on the floor, gasping for air. I knew it was the bypass but there was nothing I could do except pray. I honestly believed I was going to die, but I was so dizzy and in so much pain that I didn't care. After 2 minutes, I was able to stand up, lift the goods I had purchased and walk home. A new angiogram revealed the 3 grafted vessels had shut down completely, and lots of new collaterals had opened to save my life. If they didn't open, I wouldn't be typing this. So, when I read studies matching stenting against bypass results, I have to grin because I wonder how many were the right decision in the first place. How many of those failed bypass surgery patients would have lived if they were stented instead? It isn't just about who lives and who dies, and how long they live, it's about the right choice which is paramount. Two years after my bypass collapsed, my left artery was stented and it has been fine since. So far, that's three years success compared to three months which is living proof that the paramount decision was totally wrong. Making the right choice is not easy, but I think the patient should be far more involved because it's their body.
I will share with you a meeting I had with a cardiologist before my left artery was stented. I visited this man every single week for over a year and he just couldn't make up his mind what to do. I was in a lot of angina pain from ANY exertion and getting fed up. In our LAST meeting, he said "I have come to a decision and based this on what I believe is best for you". I was excited, thinking he was going to say he will stent. Nope, he said "I want to ablate the area of your heart which is transmitting pain, to remove your discomfort, I will use a laser and kill those cells". I sat in total silence just starring at him, thinking I was dreaming. So I asked the obvious question "how on Earth will I know if I am damaging my heart with no feelings of angina? surely I can severely damage it, even end up in heart failure?". He laughed at me and said "you can't damage it", but after about 2 minutes he seemed to change his mind and said "you know, forget that option, perhaps it isn't a good idea". I looked him in the eye and said "you know it's true what they say, you can go to all the best schools in the world, but the one thing they cannot teach is common sense. I won't be seeing you again, I will be going to a cardiologist who understands anatomy" and I then left. I really couldn't believe that guy. There are lots of great cardiologists out there, so don't think I hate them all, I have met MANY really good ones.