When Bruce Peterson went to see cardiologist Samuel DeMaio for chest pain, DeMaio put 21 coronary stents in Peterson’s chest over eight months, and in one procedure tore a blood vessel and placed five of the metal-mesh tubes in a single artery. Unneeded stents weakened Peterson’s heart and exposed him to complications including clots, blockages and ultimately his death.
Peterson’s case is part of the expanding impact of U.S. medicine’s binge on cardiac stents – implants used to prop open the arteries of 7 million Americans in the last decade at a cost of more than $110 billion.
These and other acute cases account for about half of the 700,000 stent procedures in the U.S. annually.
These sources point to stent practices that underscore the waste and patient vulnerability in a U.S. health care system that rewards doctors based on volume of procedures rather than quality of care. Cardiologists get paid less than $250 to talk to patients about stents’ risks and alternative measures, and an average of four times that fee for putting in a stent.
“Stenting abuse is by no means the norm, but neither is it a rarity” said Nortin Hadler, a professor of medicine at the University of North Carolina at Chapel Hill.
Two out of three elective stents, or more than 200,000 procedures a year, are unnecessary, according to David Brown, a cardiologist at Stony Brook University School of Medicine in New York.
It means that more than a million Americans in the past decade with implants in their coronary arteries they didn’t need, said William Boden, chief of medicine at a Veterans Administration hospital in Albany, New York. Boden was the principal investigator of a 2007 study known as Courage that found stents added no benefit over medicines, exercise and dietary changes in stable patients.
The procedure of stenting typically involves inserting the stent with a catheter through a small incision in the groin area or wrist and snaking it through to heart vessels. It usually takes less than 45 minutes.
Patients who received them are living with risks including blood clots, bleeding from anti-clotting medicine and blockages from coronary scar tissue, any of which can be fatal, according to Sanjay Kaul, a cardiologist and researcher at Cedars-Sinai Medical Center in Los Angeles.
Cardiac stents were linked to at least 773 deaths in incident reports to the U.S. Food and Drug Administration last year, according to a review by Bloomberg News. That was 71 percent higher than the number found in the FDA’s public files for 2008. The 4,135 non-fatal stent injuries reported to the FDA last year – including perforated arteries, blood clots and other incidents – were 33 percent higher than 2008 levels.
Furthermore, This July, a panel of experts convened by the American Medical Association and the Joint Commission, a hospital accreditor, named elective stenting as one of five overused treatments that too often “provide zero or negligible benefit to patients, potentially exposing them to the risk of harm.”
Elective-stent patients typically see rapid quality-of-life improvements, including in their ability to work and be active, according to Ted Bass, president of the Society for Cardiovascular Angiography and Interventions, whose members specialize in cardiac implants. The Courage trial found stents, compared to medication and lifestyle changes, were better at relieving chest pain for as long as two years after placement – a benefit that ended by 36 months.
Stony Brook’s Brown, and Boden, who led the Courage study, argue that many elective patients should be getting medical therapy before they risk stents. Only 44 percent try medication and lifestyle changes before stenting, a 2011 study in the Journal of the American Medical Association found.