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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.
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.
Oh I agree. But in my case it wasn't working and I suppose it depends on the definition of 'working'. If I stop taking my medication, I know my angina will get worse. My heart is not allowed to work as hard as it could do, so do we really class that as 'working'? Sure my heart is working or I would obviously not be typing this, but working naturally is a different thing and I suppose that's what I generally aim for as much as possible. I don't want to be on these beta blockers for the rest of my life, I want to get fit again and have a normal life. I'm not 50 years old yet and not willing to give up to medicine. I know a 4 cylinder engine will run on just three spark plugs and as long as I don't over work it, it will carry on running. However, I wouldn't be happy with it.
I agree with your philosophy though, perhaps I'm too much of a perfectionist. I was told my LAD blockage was impossible to remove, I was told stenting it was impossible. I was told by a surgeon it would all collapse in just a few weeks because the LAD was too weak from little use. Over a year later, it's all just fine. I'm glad I made the choices I did, I'm so close now to getting everything working normally again. If I did nothing I would be still gasping for breath at rest with a 5% flow through the LAD.
I agree with your philosophy though, perhaps I'm too much of a perfectionist. I was told my LAD blockage was impossible to remove, I was told stenting it was impossible. I was told by a surgeon it would all collapse in just a few weeks because the LAD was too weak from little use. Over a year later, it's all just fine. I'm glad I made the choices I did, I'm so close now to getting everything working normally again. If I did nothing I would be still gasping for breath at rest with a 5% flow through the LAD.
I believe opening a completely closed vessel (closed for a period of time sufficient to develop collaterals) can effect the collateral vessel perfusion. Also, the vessels distal to the blockage that was previously fed by the occluded vessel(s) over a period of time may not be viable and may have lost their elasticity, be weak, shrivelled etc. from lack of usage. Use it or lose it! If something is working well, don't try and fix it!
The OAT study seems to support that position....
The OAT study seems to support that position....
I had all that explained to me before they decided on a bypass. It was explained that due to a totally blocked LAD, there would almost certainly be lots of nectrotic tissue, meaning that opening the blockage would make very little, it any, difference. Further tests showed collateral development which was my life line, and meant it was a good move to revascularize my LAD. Those trials are really based on blocked vessels for over 12 hours where the tissue suffers so much, revascularization won't do anything. It doesn't seem to take into account patients who have collateral development.
When my LAD was opened last september with stents, it shocked all those present how my ecg suddenly changed and looked better. It had always been stated as being normal, but apparently there was a lot of improvemen. I also felt many benefits. I admit due to 2 small blockages at the bottom of the LAD, angina on exertion is a problem, but I can now stand in snow and breath normally. Cold weather no longer affects me which is great in the UK. Exercise has to be double what it was before to obtain angina and breathing is also easy in hot weather, whereas before I would be gasping for breath. I'm hoping the other two blockages can be treated, Ischemia is only shown in that area under exertion on stress tests.
So when there is no tissue death, I fail to see how removing a blockage will not produce benefits, when stress tests reveal Ischemia under stress and not rest?
When my LAD was opened last september with stents, it shocked all those present how my ecg suddenly changed and looked better. It had always been stated as being normal, but apparently there was a lot of improvemen. I also felt many benefits. I admit due to 2 small blockages at the bottom of the LAD, angina on exertion is a problem, but I can now stand in snow and breath normally. Cold weather no longer affects me which is great in the UK. Exercise has to be double what it was before to obtain angina and breathing is also easy in hot weather, whereas before I would be gasping for breath. I'm hoping the other two blockages can be treated, Ischemia is only shown in that area under exertion on stress tests.
So when there is no tissue death, I fail to see how removing a blockage will not produce benefits, when stress tests reveal Ischemia under stress and not rest?
QUOTE: 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?
Researching further information related to angioplasty v. medication for totally blocked coronary artery:
Study Findings Challenge Current Clinical Practice Clinical Trial Results Find Late Angioplasty after Heart Attack Offers No Advantage Over Standard Drug Therapy
Chicago — About one-third of heart attack patients do not receive treatment to open blocked arteries within the recommended 12-hour timeframe after a heart attack. Treatment such as angioplasty or clot-busting drugs may not be given because patients arrive at the hospital too late. For years it has been thought that late balloon angioplasty of these patients' arteries, if they are totally blocked, is still beneficial and might prevent future heart failure, another heart attack, or death. However, according to the results of a large international multi-center clinical trial, stable patients who had angioplasty plus stenting three to 28 days after a heart attack did no better than patients on medical therapy (primarily drug treatment) alone.
The Occluded Artery Trial (OAT) was funded by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health and is being presented today at a late-breaking clinical trial session of the American Heart Association's Scientific Sessions 2006. The study is also published online on November 14 in the New England Journal of Medicine and in the journal's December 7 issue.
"These results challenge the long standing belief that opening a blocked artery is always good. Instead, the study suggests that late angioplasty is unnecessary in this circumstance. The good news is there have been tremendous advances in drug therapy for heart attack patients. Drug thereapy is an important treatment option," said NHLBI Director Elizabeth G. Nabel, M.D.
"Our findings indicate that routine late opening of the heart attack related coronary artery is not appropriate and should be reserved only for certain patients such as those who are unstable or continue to have chest pain following a heart attack. These results should lead to lower rates of unnecessary coronary interventions in this specific group of stable patients," said Judith Hochman, M.D., OAT study chair and Harold Snyder Family Professor of Cardiology, Clinical Chief of Cardiology and Director of the Cardiovascular Clinical Research Center, New York University School of Medicine in New York City.
Researching further information related to angioplasty v. medication for totally blocked coronary artery:
Study Findings Challenge Current Clinical Practice Clinical Trial Results Find Late Angioplasty after Heart Attack Offers No Advantage Over Standard Drug Therapy
Chicago — About one-third of heart attack patients do not receive treatment to open blocked arteries within the recommended 12-hour timeframe after a heart attack. Treatment such as angioplasty or clot-busting drugs may not be given because patients arrive at the hospital too late. For years it has been thought that late balloon angioplasty of these patients' arteries, if they are totally blocked, is still beneficial and might prevent future heart failure, another heart attack, or death. However, according to the results of a large international multi-center clinical trial, stable patients who had angioplasty plus stenting three to 28 days after a heart attack did no better than patients on medical therapy (primarily drug treatment) alone.
The Occluded Artery Trial (OAT) was funded by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health and is being presented today at a late-breaking clinical trial session of the American Heart Association's Scientific Sessions 2006. The study is also published online on November 14 in the New England Journal of Medicine and in the journal's December 7 issue.
"These results challenge the long standing belief that opening a blocked artery is always good. Instead, the study suggests that late angioplasty is unnecessary in this circumstance. The good news is there have been tremendous advances in drug therapy for heart attack patients. Drug thereapy is an important treatment option," said NHLBI Director Elizabeth G. Nabel, M.D.
"Our findings indicate that routine late opening of the heart attack related coronary artery is not appropriate and should be reserved only for certain patients such as those who are unstable or continue to have chest pain following a heart attack. These results should lead to lower rates of unnecessary coronary interventions in this specific group of stable patients," said Judith Hochman, M.D., OAT study chair and Harold Snyder Family Professor of Cardiology, Clinical Chief of Cardiology and Director of the Cardiovascular Clinical Research Center, New York University School of Medicine in New York City.
Thank you for your response. I want to compliment you and your husband for doing some research and asking the correct questions. I'm not aware of the OAT trial, but I and maybe others will review the trial conclusions. Take care
Thank you for all of your comments. As you can see, there are two roads my husband can take, stent placement or medical management. After my post, I discovered the OAT trial which concluded that delayed stenting after heart attack is not superior over medical management. I think that the interventional cardiologist who tried to place a stent in the 100% blocked artery was just following protocol to stent arteries tht are more than 75% blocked. Since he was unable to do it, and he saw that my husband has collaterals supporting that area, he concluded that he should be okay with just medical management. My husband will have a stress test in a few weeks and we will also be seeking a second opinion. Thanks again for your comments.
QUOTE: 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?
>>>>>>Collaterals are enough if there is good perfusion to location in question. My cardiologist saw a completely occluded LAD during angioplasty for the RCA, and stated he could not stent LAD after an attempt. As it turns out a break through stent implant was not necessary...my enlarged heart and low EF was effectively treated with medication. I had had a heart attack, impaired heart wall movement, and EF below 29% (heart failure range). Now, completely recovered with normal size heart and good EF.
Some intervential cardiologist are programmed to stent whether necessary or not. Apparently, it is/was not a critical issue for me or bangs' husband otherwise there would have been an emergency by-pass for husband, and I would have had a bypass as well. The fact remains it wasn't necessary to stent the LAD based on my current heart status and that speaks for itself. My LAD is totally occluded midway, and there isn't any way a person can survive if there aren't collaterals!
Also, the fact there has been a recovery with husband's condition indicates a stent isn't/wasn't necessary because the EF is normal and that speaks for itself. A bypass or stent will not prevent a heart attack! Is a stent going to increase the EF? I think not. Is there angina uneffected by medication that requires stent therapy? No! Is a stent or bypass going to increase longivity? Studies show there is no effect.
>>>>>>Collaterals are enough if there is good perfusion to location in question. My cardiologist saw a completely occluded LAD during angioplasty for the RCA, and stated he could not stent LAD after an attempt. As it turns out a break through stent implant was not necessary...my enlarged heart and low EF was effectively treated with medication. I had had a heart attack, impaired heart wall movement, and EF below 29% (heart failure range). Now, completely recovered with normal size heart and good EF.
Some intervential cardiologist are programmed to stent whether necessary or not. Apparently, it is/was not a critical issue for me or bangs' husband otherwise there would have been an emergency by-pass for husband, and I would have had a bypass as well. The fact remains it wasn't necessary to stent the LAD based on my current heart status and that speaks for itself. My LAD is totally occluded midway, and there isn't any way a person can survive if there aren't collaterals!
Also, the fact there has been a recovery with husband's condition indicates a stent isn't/wasn't necessary because the EF is normal and that speaks for itself. A bypass or stent will not prevent a heart attack! Is a stent going to increase the EF? I think not. Is there angina uneffected by medication that requires stent therapy? No! Is a stent or bypass going to increase longivity? Studies show there is no effect.
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.
"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.
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.
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%.
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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%.
.
"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.
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.
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.
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.
"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.
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.
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