Are coronary stents necessary?

• Kerala Chief Minister V.D. Satheesan’s recent remarks questioning “unnecessary” angioplasty procedures have drawn objections from medical organisations concerned that it could undermine public confidence in doctors. But the Chief Minister’s remarks demand more than a reflex response; it requires a thoughtful, honest response built on up-to-date evidence based on clinical and research studies.
• Percutaneous Coronary Intervention (PCI), by balloon angioplasty and stent placement, has transformed cardiovascular care. During an acute heart attack caused by a suddenly blocked coronary artery, prompt angioplasty and stents can restore blood flow, save heart muscle and improve survival. There is no debate about this approach and second opinions are unnecessary as time is of essence in such an emergency. Stents also offer substantial relief to selected patients with persistent activity-limiting angina (chest pain caused by lack of oxygen-rich blood).
• There is a crucial distinction between stenting as a life-saving measure in the above situations to medical treatment via stenting because a narrowing of blood vessels is seen on an angiogram. A coronary angiogram shows the anatomy of the arteries; it does not, by itself, establish that a narrowing requires intervention. The decision to intervene and how to intervene must take account of the patient’s symptoms, the severity of the blockage, its effect on blood flow, the overall pattern of coronary disease and the expected benefit of intervention.
• The landmark ISCHEMIA trial, published in The New England Journal of Medicine in 2020, enrolled 5,179 patients at 320 sites in 37 countries with stable coronary artery disease and moderate to severe ischemia (restricted blood flow to the heart). The patients were assigned either to an initial invasive strategy — angiography followed by angioplasty or coronary bypass surgery — or to a conservative strategy of optimal medical treatment, with revascularisation reserved for those who had an acute event or angina. After a median follow-up of 3.2 years, there was no significant difference between the two groups in composite outcomes (cardiac arrests, hospitalisation for unstable angina or heart failure) and all-cause and cardiovascular mortality were similar. After a follow-up of 5 years, there was still no significant difference between the two groups in composite outcome or mortality. The core lesson is that most patients with stable coronary artery disease with ischemia on optimal medical treatment would do as well as those who undergo stenting or bypass surgery.

Dr. Enas A. Enas

• Preventive Cardiologist and Physician-Scientist, Founding President of the CADI Research Foundation USA

Dr. Basil Varkey

• Professor Emeritus of medicine

Concerning scale

• The growing scale of PCI in India deserves careful examination. National Interventional Council figures show that annual PCI procedures rose from approximately 1,13,000 in 2008 to more than 7,26,000 in 2024 — an increase of more than six-fold. In contrast, PCI procedures in the U.S. fell by about 40% between 2003 and 2016, reflecting progress in prevention and treatment.
• These figures do not by themselves prove that stents are overused in India considering its large population, the substantial burden of premature coronary disease, the socio-economic progress in the past decades and the improved access to cardiac care centres. Nevertheless, the divergence in trends between the two countries raises an important question: how much of the increase in PCI is a reflection of fulfilling a genuine clinical need, and how much of it is a reflection of differences in practice patterns, financial incentives and gaps in knowledge on the efficacy of optimal medical treatment?
• Optimal medical therapy, based on evidence-based guidelines, is the foundation of care for all coronary artery disease patients. The elements of optimal therapy include LDL-cholesterol lowering, appropriate anti-platelet treatment, blood-pressure control, evidence-based diabetes management and lifestyle changes. A coronary stent treats a specific narrowing; it does not cure the underlying disease of atherosclerosis or eliminate the risk of future heart attacks. Patients remain vulnerable to disease elsewhere in the coronary arteries and must continue preventive treatment.
• The way forward is neither condemnation of cardiologists nor unquestioning acceptance of every recommendation for angioplasty. Most doctors strive to act in their patients’ best interests, but no profession is immune to inappropriate practice. The ultimate test of healthcare is not how many procedures are performed, but how many lives are saved and whether patients receive the right treatment at the right time at an affordable cost.