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Most Angioplasties Unneeded, According to New Study

Half a million patients a year with chest pain are getting unnecessarily or prematurely treated with stents to open blocked arteries when drugs are just as effective, according to an upcoming study in the New England Journal of Medicine.

Stenting is an increasingly common procedure where a tiny balloon is inserted into a severely blocked artery, and then removed, leaving the device to hold the artery open. Stents were developed to combat the tendency of many blood vessels to close quickly after an angioplasty. Angioplasty and stenting usually cost between $25,000 and $50,000.

The New York Times reports:
Since 2002, practice guidelines from the American Heart Association and the American College of Cardiology have called for using angioplasty and stenting — or bypass surgery, an even more invasive alternative — only after extensive efforts to treat the symptoms of such patients with drugs. But they have been increasingly ignored, cardiologists say, by patients and doctors choosing the more immediate and initially reliable relief provided by stenting.
Patients who received stents did not live longer or have fewer heart attacks than patients treated only with drugs. In both groups, 7 of 10 were free of chest pains after 5 years of treatment.

Previous studies have shown that stenting is recommended for patients who have poor blood flow to the heart during stress or exercise that isn't relieved by rest or medication. Stenting can also save lives when used during heart attacks.

But a half million Americans who get stents fall into the group in this study that isn't believed to be in danger of a heart attack despite accumulated plaque narrowing the coronary arteries by 70% or more.

"You are not putting yourself at risk of death or heart attack if you defer," and considering the safety worries about drug-coated stents putting patients at increased risk of blood clots, it may be wise to wait, said Dr. Steven Nissen, a Cleveland Clinic heart specialist and president of the College of Cardiology.

The study is not without its detractors - especially from companies who manufacture stents, which generate $3B in sales, and doctors who perform angioplasties.

One of those doctors spoke at a meeting sponsored by stent maker Boston Scientific Corp., and was responsible for the leak of the study's results, which weren't due out until Tuesday.

The study "was rigged to fail, and it did," said Dr. Martin B. Leon of Columbia University to several hundred of his colleagues Sunday night. "A lot of people have been taking shots at us, and we need to go on the offense for awhile." Columbia responded by saying that it was "extremely disappointed" that the study's results were released prematurely, and "will be considering strong sanctions againgst the individual or individuals involved."

As for why angioplasty doesn't help more, experts point out that it treats only one affected artery at a time, while drug therapies work on all arteries. Also, the kinds of blockages treated by angioplasty tend to be less lethal.

"Even though it goes against intuition, the blockages that are severe that cause chest pain are less likely to be the source of a heart attack than segments in the artery that are not severely blocked," said Dr. David Maron, a Vanderbilt University cardiologist who helped lead the new study.

"Often I think that patients are under the impression that unless they have [a stenting] procedure done, they're not getting the best of care and are at increased risk of having a heart attack and die," continued Dr. Maron. "This study shows that is not true."
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