Should I Have a Stent?

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rich01

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When I had a heart cath back in January of this year, they discovered I had major plaque blockage in OM2. They said it was about 70%. I was told I needed a stent or bypass surgery in addition to valve replacement.

I have since changed to a different cardiologist at a different heart center and in reviewing the data, he said he thought it was closer to 80% and agreed I should have a stent.

I asked why have a stent when I do not have angina. From the look on his face, I don't think he was expecting that question. He said something about extra pressure during the operation. I didn't follow up, so I'm not sure why there would be additional pressure and why it would be an issue.

The reason I am asking is that studies show that stents are life saving during a heart attack, but in other cases do not reduce incidents of heart attack and do not prolong life. I think hospitals are dragging their feet about reducing the number of stents because it is a billion dollar a year income stream.

I've tried to have this discussion for my primary care doc, but this is something she wasn't aware of. I know I need a new aortic valve, but I don't think I need a stent. The cardiologists seem to have the attitude "we might as well do it while we are in there".

If I thought it might help, I would get it and take warfarin or whatever anti-coagulant they prescribe, but I think taking vitamin K is more important than warfarin.

How would you make this decision where the scientific literature says one thing and your cardiologist says the opposite?

Symptomatic relief is the primary goal of percutaneous coronary intervention (PCI) in stable angina and is commonly observed clinically. However, there is no evidence from blinded, placebo-controlled randomised trials to show its efficacy.

Conclusions
As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy. (ClinicalTrials.gov number, NCT00007657.)
 

pellicle

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Because surgeons cut or they don't get paid.
I agree with duffey, and surgeons don't uaually do stents do they? Isn't that an interventional cardiologist?
Also while a surgeon may be biased they do have to follow ethics.
As always, get a second opinion (I don't know of any of us here who are surgeons or cardiologists)
 

rich01

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I agree with duffey, and surgeons don't uaually do stents do they? Isn't that an interventional cardiologist?
Also while a surgeon may be biased they do have to follow ethics.
As always, get a second opinion (I don't know of any of us here who are surgeons or cardiologists)
Why would you think cardiologists would be up to speed on scientific studies? If they haven't read the studies, they aren't violating their ethics when they recommend a stent.

The same person that does my valve replacement would be the one that does the stent, if I get one. Having that discussion with him is a no win situation. I certainly don't want to be challenging the knowledge and expertise of the surgeon right before he goes into my heart.

I have seen 6 different cardiologists over the last 4 years and I have been surprised at how their knowledge appears to stop with what they learned in med school many years ago, plus what they have learned in seminars held by drug companies and device manufacturers. They don't have time to keep up with current scientific literature. If they did, they wouldn't be putting in anywhere near the number of stents they do now.
 

pellicle

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Why would you think cardiologists would be up to speed on scientific studies?
I'm probably the most cynical person on this board, but:
  • how do you know the surgeons are not the same (given some of the rubbish I've seen reported here coming out their mouths)
  • how do you know this covers all cardiologists (and I'm very sorry to read that the USA does not have any standards of ongoing professional training and assessment)
  • why do you think anyone on this board would know more?
I certainly don't want to be challenging the knowledge and expertise of the surgeon right before he goes into my heart.
the logic of this is frightening, you either agree with them or you can't even ask questions for fear they'll punish you when you're on the table.
 

Duffey

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Let me try to paraphrase what I understand from your thread replies. You have seen six cardiologists in four years, and don’t trust any of their recommendations regarding the need for a stent with an 80% blockage? In addition, you believe your surgeon, which you have not consulted with yet, can’t be trusted to give you an unbiased, professional opinion. What if the surgeon recommended no stent? As Pellicle’s states, none of us are qualified to answer your question, and I have a feeling that if we did say yes, get the stent, you would not accept our advice. It’s your heart, you should be able to do what you want, if you can find a surgeon who is agreeable.
 

rich01

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Let me try to paraphrase what I understand from your thread replies. You have seen six cardiologists in four years, and don’t trust any of their recommendations regarding the need for a stent with an 80% blockage? In addition, you believe your surgeon, which you have not consulted with yet, can’t be trusted to give you an unbiased, professional opinion. What if the surgeon recommended no stent? As Pellicle’s states, none of us are qualified to answer your question, and I have a feeling that if we did say yes, get the stent, you would not accept our advice. It’s your heart, you should be able to do what you want, if you can find a surgeon who is agreeable.
I don't know how you came up with that from what I posted previously.

The 1st cardiologist told me it was impossible to lower cholesterol through diet and that niacin doesn't work to bring down LDL. I know that is not true as my cholesterol is exactly where they want it to be based on diet and niacin.

The 2nd cardiologist completely ignored the reason I had gone to him in the 1st place. Every evening, starting about 5 pm, my blood pressure would start going up until it reached about 220/130. About 1 am it would peak, and then by 6 am would have returned to high normal.

The ER, several doctors including cardiologists, had no clue as to cause and just kept writing prescriptions for meds that didn't have any effect. It took me 2 years to figure out the cause, and I haven't experienced a spike in almost a year. I believe the same thing that caused the BP spikes caused the plaque buildup in aortic valve and arteries. If that is true, then the plaque is likely stabilized.

I believe the 3rd cardiologist was in early stage of dementia. He ignored everything I told him, and the nurse hurried him out of the room after just a few minutes.

The 4th was OK, but with a diagnosis of severe AS, I decided to see a cardiologist at a high ranking medical facility that was participating in the TAVR trial.

The 5th was at that facility. All was well until I think he had a disagreement with and was over-ruled by the TAVR committee. He went from being very co-operative and informative to refusing to provide any information. He had told me one day things were urgent and then 3 days later sent me a message saying to come back in 5 months. I tried several times to get an explanation, but none was forthcoming.

The 6th is at another major university, also participating in the TAVR trial. At this point, I have only had the initial consult and another echo. I have a follow-up next month.

I have brought up diet with most of the cardiologists. None were supportive. I even asked if they knew of a cardiologist that used diet to treat plaque and they said no. One said he had heard of someone, but didn't know his name.

The thing is, in the US, the Ornish Program and Pritikin Program are both approved by Medicare for cardiac rehabilitation:

Medicare Part B (Medical Insurance) provides coverage for a cardiac rehabilitation or physical therapy program if you’ve had at least one of these conditions:
  • A heart attack in the last 12 months
  • Coronary artery bypass surgery
  • Current stable Angina pectoris (chest pain)
  • A heart valve repair or replacement
  • A coronary Angioplasty (a medical procedure used to open a blocked artery) or Coronary stent (a procedure used to keep an artery open)
  • A heart or heart-lung transplant
  • Stable chronic heart failure
So if diet based programs are approved by Medicare and some insurance companies, and there are scientific studies confirming that diet can stabilize and reverse heart disease, why didn't any of these cardiologists know about it?

I wanted to go to a center that has a Pritikin Program onsite, but unfortunately I couldn't find any within driving distance that participate in the TAVR trials. As I am considered a low risk patient, the only way I can get TAVR is through a trial or to pay for it myself, which I can't afford to do.

I first learned I needed a stent in January of this year. About 2 hours after the cath, I was laying in bed and my cardiologist came in and in a loud and serious voice said I needed either bypass surgery and open heart surgery for valve or a stent and TAVR because they had found plaque in my arteries. The cardiologist that did the cath was with him and gave him a "look".

He gave me, and my sister who was with me, the impression that this was urgent. He had me talk to the surgeon, a very nice guy, who talked to me for a couple of minutes and then said "I don't know why he wanted me to talk to you".

Two days later they held there weekly meeting and after the meeting my cardiologist sent me a message saying that my condition was determined to not be serious and to come back in June ( 5 months later). I asked why my status had changed from serious to not serious and he wouldn't give me a straight answer. I tried several times to get an explanation and he refused to provide an answer.

I thought about if for a few weeks and realized I had lost confidence in the cardiologist. The question was what to do about it. I did some research to see if there were any other nearby facilities participating in the TAVR trial. There was and I decided to see if I could get into the trial. That's where things stand now, except I am asymptomatic and you have to have symptoms to participate.

So I am in a watch and wait state right now. I was hoping that this cardiologist would work with me during that time to try to stabilize/reduce plaque in my OM2 and avoid needing a stent. He isn't up on using diet and didn't know anyone to refer me to.

The closest Pritikin Program is about 4 hours away and they meet 2 times a week. I am already following the basic program, so probably wouldn't get much out of it, but it would put me in touch with professionals, hopefully including a cardiologist, that are open to using diet and exercise to avoiding getting a stent. But again, I don't qualify as I don't have angina.

My primary care doctor is working with me. On my own I got a CIMT and a Cleveland Clinic Inflammation Panel. I hope to get another CIMT in a few months to see if I have been able to reverse plaque buildup. My CIMT shows I have lots of plaque, but none is what is called hot plaque or soft plaque. My Cleveland labs are show low risk for heart disease, which I think means in the last couple of years, through diet and exercise and fixing my leaky gut, I have reversed the conditions that caused the plaque buildup.

I understand there are no scientific studies showing that aortic stenosis can be reversed through diet or supplements. But I also know there are several studies that show that arterial plaque can be stabilized and reversed with diet and exercise. I just wish I could find a cardiologist that also knew that and was willing to work with me on avoiding a stent.

I trust the surgeon to replace my valve. Since I hopefully will be in a trial, the valve is determined by the trial. If I have to have a stent, I will rely on the professionals to use the right kind of stent.

But I don't trust cardiologists or surgeons to make the best choice when it comes to rehab. And that is what i see my question about stent or no stent as. Can I, through rehab (in this case diet and exercise) avoid having to have a stent. I think the answer is yes, but how do I convince my cardiologist of that?
 

carolinemc

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When I had a heart cath back in January of this year, they discovered I had major plaque blockage in OM2. They said it was about 70%. I was told I needed a stent or bypass surgery in addition to valve replacement.

I have since changed to a different cardiologist at a different heart center and in reviewing the data, he said he thought it was closer to 80% and agreed I should have a stent.

I asked why have a stent when I do not have angina. From the look on his face, I don't think he was expecting that question. He said something about extra pressure during the operation. I didn't follow up, so I'm not sure why there would be additional pressure and why it would be an issue.

The reason I am asking is that studies show that stents are life saving during a heart attack, but in other cases do not reduce incidents of heart attack and do not prolong life. I think hospitals are dragging their feet about reducing the number of stents because it is a billion dollar a year income stream.

I've tried to have this discussion for my primary care doc, but this is something she wasn't aware of. I know I need a new aortic valve, but I don't think I need a stent. The cardiologists seem to have the attitude "we might as well do it while we are in there".

If I thought it might help, I would get it and take warfarin or whatever anti-coagulant they prescribe, but I think taking vitamin K is more important than warfarin.

How would you make this decision where the scientific literature says one thing and your cardiologist says the opposite?


You need to ask your cardio questions about this, for that is what the cardio is supposed to do and you to follow up, be proactive in your heart health. And also talk to the surgeon, for both of them are to be working for your well-being. So sorry you are getting so much information in so many directions that it is all confusing. Hope this gets cleared up before your surgery date. You have had a bad run of cardio in the same place. Better to get other opinion at other hospitals. When you go see another doctor at the same place, they tend to confer together and you will never get the right answer with a group at the same place. Go with your gut feeling, if it does not feel right, leave and get a better doctor somewhere else. It happens, ask a few here, they have had to go to several cardio at different hospitals before they got the one who cared. Good luck in what you do decide. Hugs for today.
 

carolinemc

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I agree with duffey, and surgeons don't uaually do stents do they? Isn't that an interventional cardiologist?
Also while a surgeon may be biased they do have to follow ethics.
As always, get a second opinion (I don't know of any of us here who are surgeons or cardiologists)
Cardiac surgeons do put in stents, not the cardiologist, for the cardiologist is not a trained surgeon. Food for thought.
 

trinitymcdermott

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Seattle, WA, USA
I have not read through the replies, but wanted to give some input - hopefully not repeat.
- stents are rarely placed during open procedures, but through percutaneous access - usually at your groin or arm.
- if they do open and are willing to do bypass at the same time as your AVR, not a bad idea, but I would guess there may not be enough time - you may be under too long.
- the stent is not related to your AV (sends blood to the aortic artery and then the body). It is likely a coronary artery they are talking about, which provides blood to the heart.
- an 80% blockage could cause blood to pool in that area, causing clot, which could cause stroke. symptom of the blockage.
- have they tried balloon angioplasty on this stenotic spot yet? That sometimes is a starting point before a stent, but it may be too stenosed. The good thing is, again, it’s done percutaneous in the cath lab, not open.
- doc may be right that your heart may need a better blood supply AVR post surgery.
 

pellicle

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Last edited:

AZ Don

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So if diet based programs are approved by Medicare and some insurance companies, and there are scientific studies confirming that diet can stabilize and reverse heart disease, why didn't any of these cardiologists know about it?
Here's your answer:
Less than a quarter of medical schools have even a single dedicated course on nutrition, and less than six percent of graduating physicians may have received any formal nutrition training. Out of thousands of hours of pre-clinical instruction, your doctor may have gotten an average of three hours of nutrition training. There was even a study published in The American Journal of Clinical Nutrition that pitted doctors versus patients in a head-to-head test of basic nutrition knowledge—simple true or false questions. Guess who won? The patients. People off the street knew more about nutrition than their doctors, yet people still ask their doctors for nutrition advice.
from https://nutritionfacts.org/video/doctors-nutritional-ignorance/

But I also know there are several studies that show that arterial plaque can be stabilized and reversed with diet and exercise. I just wish I could find a cardiologist that also knew that and was willing to work with me on avoiding a stent.
I imagine that most Cardiologists are just recommending what they know. Perhaps Pritikin, Ornish, or even Dr Greger who I quoted above (and is not a Cardiologist but was inspired to focus on diet by the reversal of his Grandmothers heart disease in one of Pritikin's early trials) could help you find one. Alternatively, if you can find what you need from a source other than a Cardiologist, then you can go back to the Cardiologist and confirm that the stent is no longer needed. Ultimately you decide what path to take. I can tell you that reversing heart disease takes a higher level of commitment to diet and lifestyle changes than simply trying to prevent it in the first place. Good luck.
 

vitdoc

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I don't think most cardiologists think that diet is not important. Clearly reducing various fatty components in the blood appear to be a good thing in statistically reducing the chance of plaque build up. Diet does help but may be inadequate and may not be followed by everyone. So drugs to reduce cholesterol are used and have been shown to be helpful in large prospective trials.
Angina is not necessary a requirement for a decision on dealing with coronary artery disease.
The first symptom can be death. One can look in the medical literature and cherry pick whatever you want to find. I am a physician but not a cardiologist but an 80% blockage sounds pretty worrisome. Stenting is generally done by interventional cardiologists bypass by cardiac surgeons.
There are various criteria to decide on stenting vs bypass. If the area can be stented that probably is easier and safer than bypass. The only issue with placing a stent and a valve is that for a mechanical valve you need to be on warfarin. For a stent you need to be on an anti platelet agent such as Plavix for at least a year. So one would be on both agents for a year if the valve and stent were done together. Why don't you bring in your literature that suggests that stenting is only required if you are symptomatic to a cardiologist to review with you. I have patients bring things to me which often are fourth rate in quality. Be careful of DR. GOOGLE. Also don't assume that every physician is stupid or a crook.
 

pellicle

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I always wonder why so many people are still having open heart surgery for aortic valve replacement when TAVR appears to be as safe or safer. Mick Jagger was out on tour about 4 weeks after having his aortic valve replaced by TAVR.
because all the data we have so far shows that it is of very limited life (certainly well under tissue prosthetic) and because of that its aimed at patients who are too frail to undergo traditional surgery.
It will be interesting to see how Mick goes longer term.
 

rich01

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because all the data we have so far shows that it is of very limited life (certainly well under tissue prosthetic) and because of that its aimed at patients who are too frail to undergo traditional surgery.
It will be interesting to see how Mick goes longer term.
My cardiologist said about 15 years. And I was really thinking about people in their late 60's and older. I know a couple of people in there 60s, otherwise healthy, who had insurance that covered it.
 

Suckyvalvegurl

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I had truly minimally invasive surgery for my valve replacement in February. I am 56 so didn't qualify for TAVR. I also had completely asymptomatic critical AV stenosis from a birth defect (bicuspid valve). My surgeon was great and very highly rated. My sternum was not opened in any way. He told me before I had my cath that if needed he can usually also place a stent at the same time. I didn't need one though. You might look into Dr. Doolabh at UTSW. I was back at work within a week although most people take 2 weeks off.
 
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