The dark side, and upside, of stents

September 03, 2010

I have been following the "stent scandals and controversies" very closely in your paper. I treat diabetics among whom the incidence of coronary heart disease and heart attacks is very high. Most long-term diabetics will need a consultation with a cardiologist sometime during their life, either to prevent heart attacks or to treat one that has already happened.

I remember when coronary artery bypass surgery was considered a preferred treatment over stents for diabetics but that was way before stents became commonplace, particularly the drug eluting ones. In the time before stents became all the rage, cardiologists were cautious about the procedure, placing one or two stents at one sitting, but with experience the confidence of the interventionists grew and they began to insert as many as three stents at one sitting.

Whenever my diabetic patients return to me after one of these procedures, I am struck by how routine stenting has become. A week or two after the procedure my patients are up and about and during a visit to my office they are quite worshipful of their cardiologists. My own subject of specialty, endocrinology, has few gimmicks or money-fetching procedures and my diabetic patients are my peep holes to the mighty and highly regarded world of interventional cardiology.

Today all kinds of jujitsu are possible in the realm of stenting, with stents being inserted into stents and one artery being made patent with 5 stents in place. When my patients tell me proudly that they have five stents in one artery or a total of ten stents distributed over their various coronary arteries, I dare not belittle this achievement of modern technology by paying it no attention. I always give these stories the appropriate gasps in my office, my eyes hopefully reflecting my amazement, but I cannot help what my sagacious head exasperatedly takes note: that stents have made it seem like coronary artery disease, often a lethal and progressive condition, is endlessly manageable and stents have corrupted my patients' desire to change their life styles.

"Here I am in my office," I would tell myself, "trying to get these patients to give up that ice cream or that apple pie, and in comes the cardiologist with his catheter and his stents to perform his miracle after which, the patients emerge from the cath lab with a new lease on life, reassured the apple pie or the ice cream could do them no harm and if it did, there is always another stent to be inserted where the harm has been wrought, or a stent within a stent or a row of pretty little stents."

No joke! To most American patients, stents are wonderful devices; like liquid Drano to the plumber, so the stents to the cardiologists, these patients imagine. But in reality after stents are inserted dangerous clots can form within them or opened up arteries can get reclogged or patients consigned to taking powerful blood thinners for the rest of their lives can bleed into their brains or other parts of their bodies, suffering new complications.

It is not that my friends in cardiology do not explain these tragic side effects of stent insertion to their patients; it is simply that many American patients, in shock and awe about the latest technologies to arrive on the horizon, will submit themselves with utmost optimism to procedures they have not completely researched or understood and even when their doctors are cautioning them about the dark side of the technologies used, these patients will only half hear what is said, their ears dulled by the sound of tall, frothy milk shakes, they dream themselves sucking, through long straws, or cigarettes they hear themselves drawing on, most pleasurably, after technology has made them whole.

Such is the fascination for technology in America and the zest for good living that doctors who are doing the yeoman work of changing bad lifestyles, one patient at a time, are essentially losers in the financial arena. Insurance companies that talk a mile a minute about increasing reimbursements for primary care doctors and for preventive medicine, have done so reluctantly, throwing a morsel at a time to the not-so-glamorous specialties. Hospitals love their interventional cardiologists more then their infectious diseases specialists, because the former can make the hospitals' stars shine in the world of advertisement and publicity while the latter have to mostly resign themselves to "unsung and unknown" status. I have to assert that interventional cardiology, as a glamorous profession, is not an invention of the cardiologist alone; instead, responsibility for this exalted status has to be shared by society as a whole, with patients demanding quick fixes for all their ailments, insurance companies, for quite a long while, paying heftily for these quick fixes and hospitals lusting after those payments.

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