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Stenting vs. Medical Management

My husband had a heart attack one month ago.  His distal circumflex is 100% blocked.  Attempted to stent it and it was too calcified to stent. He has very good collaterals in this area.  Proximal LAD is blocked 50%.  Mid RCA is blocked 60%.  1st marginal is blocked 50%.  1st diagonal is blocked 70%.  Interventional cardiologist said he will do fine with medical management.  He said that stents do not prevent heart attacks and can cause their own problems.  He has no angina.
We followed up with another cardiologist who recommended that the 100% blocked distal circumflex be stented as well as the 60% blocked and 70% blocked arteries.  This is the treatment he recommends to preseve my husband's quality of life down the road.  He unblocks 100% arteries 100 times a year.  His echo is normal after heart attack and his ejection fraction is 60%.  The interventional cardiologist who performed the procedure said he basically has no heart damage.

Husband feels good right now.  He is on Plavix, daily aspirin, Toprol and Lisinopril.

Should we go the medical management route or go with the stenting?  Thank you for your time.
13 Responses
976897 tn?1379171202
"He said that stents do not prevent heart attacks"

Well that Cardiologist has said and done it all really, talk about contradiction.
He has attempted a stent, due to a heart attack, then claims they don't stop them. Due to his failure he has conjured up the idea that medication is fine on its own. The medication is the ONLY thing stopping another attack and to stay in that situation is a big gamble.
I think your new Cardiologist is on the ball, think of your FUTURE. I would get the stenting done and nip this in the bud. If the blockages are allowed to develop much more, particularly the one in the proximal LAD, he will require bypass surgery down the line. Having had both bypass surgery and stents, I can tell you first hand that stenting is much easier to deal with.
If your husband decides to go ahead with stenting, ensure that the hard blockage in the circumflex is lasered or rotablated first to remove as much of the material as possible before stenting. I had this done in my Circumflex in feb 07 and the stent is still fully clear with no disease forming. Some cardiologists seem to just squash a stent into the artery with a lot of hard plaque still there. I'm sure this is what causes discomfort in some people after stenting and I've seen some nasty images of stents done this way. When you look at my angiogram images, you would never be able to spot my stent. Cardiologists have to look at my records to see exactly where it is.
367994 tn?1304957193
I have answered your other post on the subject.  I didn't catch the double post until now, and it would be better to have had the same questions on one post.  

Ed is a walking stent :) with numerous heart issues and lots of heart pain angina, no collaterals and apparently there are issues going forward.    He has his experience.  I have my experiences that differ but medically sound for the past 7 years...no problems whatsoever. I suggest interested readers to google the COURAGE study and that confirms what your interventional cardiologist (being an intervention cardiologist adds to credibility) doctor said about not preventing heart attacks. There is evidence many angioplasty have been unnecessary....I recently posted the information and link to the study.

To open a collaterlized vessel will decrease the arterial pressure that caused the collaterals to open and blood will flow through vessels with least resistence and that will be the blocked vessel...now no blood flow through the collaterals.  As stated in the other post I have had and continue to have a 100% occluded LAD with good clollateral flow, 72% occluded circumflex that is/has been treated with medication.  Subsequent tests show no progression and symptom free.

My experience is not unique, and because of the success of medical therapy there are fewer individuals posting compared to individuals that have been numerously stented and have problems.The risk for a stent implant can be clot formation and heart attack, restenosis with scar tissue, infection, artery rupture, etc.

976897 tn?1379171202
"Ed is a walking stent :) with numerous heart issues and lots of heart pain angina, no collaterals and apparently there are issues going forward"

Well not strictly true.
In Feb 07 I had several MI events and my Circumflex was stented. Then it was noticed I had a blockage in my LAD but collateral vessels were feeding the vessel. In Aug 07 I had angina return and it was established that my collaterals were no longer sufficient, leading to a triple bypass. Three months after the bypass, it failed leaving only ONE alternative, stenting. Stenting is what I wanted in my LAD in Feb 07, but nobody listened. Things got worse and then a failed bypass. If they had listened to someone who knows their own body, it would have been sorted out years ago.
I apparently have two very small blockages right at the bottom of the LAD, which if they can be stented, means a normal heart and life again. I'm still waiting to hear the verdict on that decision.
This is why I don't believe in hanging around too long for action. It's also why I don't like to rely on collaterals. There are risks with stents, but that's why I made sure I found someone with good experience to re--open my LAD with 5 stents. 30 years experience, and the cardiologist who did the first stent in the UK, he was the best bet. The way my collaterals were losing their effect, you should see how thin my LAD was. A Cardiac surgeon estimated around 5% flow through the vessel, and once zero, it would be game over. I had two choices, do something or die.
367994 tn?1304957193
I could have sworn you said you didn't or wasn't able to develop collaterals, etc., etc.  I know you are very careful and you would only go to the best doctor and the best teaching hospital, etc.  Anyway from reading your posts you have done a lot self evaluation, personal opinion about the correct procedure for you, what were the successes and what were the failures, etc.

QUOTE: "His echo is normal after heart attack and his ejection fraction is 60%.  The interventional cardiologist who performed the procedure said he basically has no heart damage".

The heart is functioning normally so why should there be any intervention?  But there is something unclear and that is having a heart attack and no heart muscle damage and an EF 60%.  A heart attack by definition is heart muscle damage, and heart muscle damage reduces the EF.  Husband's EF is normal and no heart cell damage.  I wasn't as lucky, I had heart cells as it turns out to be only stunned and brought back function normally with a better blood supply and my EF was below 29%.

976897 tn?1379171202
"The heart is functioning normally so why should there be any intervention? "

What obviously concerns me is this "My husband had a heart attack one month ago".
And this "Attempted to stent it and it was too calcified to stent". So, how did they stop the heart attack? medication? I realise they state he has collaterals, but are these enough?
I had collateral feeds into the left side, which I have always stated, but they couldn't seem to keep up as my main native vessel continued to shrink.
It also seems very odd how a cardiologist would attempt to stent, which was obviously the best solution at the time, then due to failure suddenly say there is no need? Very odd indeed. I don't think that cardiologist was being straight with such contradictions and would be very wary. I also don't think the best solution is keeping away symptoms with medication. Beta blockers are great at hiding symptoms. If I come off mine, I notice a HUGE difference in angina levels. So, weighing all this up, my personal opinion is to have the blockages treated. On a last note, I had 12 cardiologists tell me that my total blockage was impossible to remove. The experienced one I found managed it, although it was hard going due to the rock hard calcification. It just goes to show how inexperience can drive decision making.
1346447 tn?1327866172
Each case is unique. If suffering angina remedy lies in medication or stent or bypass depending on the extent. If no problem inspite of angiogram showing blockages I think medication should help. Worst part is doctors becoming commercial minded. My own experience with second openion from my doctor of confidance I have avoided un-necessary bypass surgery. Sudden heart attacks without warning signs are even there with stents and bypass surgeries.
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