Keralam CM calls out ‘unnecessary’ angioplasty: Who needs a stent, who doesn’t?

Kerala Chief Minister V D Satheesan’s call for a campaign against ‘unnecessary’ angioplasty — a procedure to open a narrowed or blocked heart artery with a small balloon, often followed by placement of a stent to keep it open — has sparked a debate among doctors. Satheesan said some hospitals were carrying out angioplasty despite there being no medical need for it, putting the focus on a procedure that can be life-saving in some situations but may not be necessary in others.

The Indian Medical Association (IMA) has agreed that unnecessary investigations and treatment should be avoided, but has cautioned against broad claims about unnecessary angioplasty. Such statements, it said, could undermine patients’ trust in doctors and even prompt some to delay or refuse procedures that are genuinely life-saving.

Kerala is among the country’s largest users of coronary stents, ranking third in reported stent use after Maharashtra and Karnataka, according to National Interventional Council data.

Cardiologists say angioplasty is not required for every patient with chest pain, but it should not be delayed when a patient is having an acute heart attack, when blood flow to a part of the heart is suddenly blocked because of blood clotting over broken plaque, depriving the heart muscle of oxygen. The decision, they stress, has to be made on a case-by-case basis, taking into account the patient’s clinical condition, investigation findings and risk factors. How then do doctors determine which patients need the procedure, which do not, and when delaying it can be dangerous?

When do we need angioplasty?

“Coronary angioplasty can be life-saving when performed promptly during a heart attack. However, in non-acute situations or stable coronary artery disease, (when the heart’s arteries are narrowed, predictable and do not pose an immediate emergency) its role is more limited. Several large studies have shown that, for most patients with stable disease, routine angioplasty and stenting do not provide additional protection against death or heart attack compared with treatment with medicines only,” says Dr Ambuj Roy, professor of cardiology, All-India Institute of Medical Sciences (AIIMS), Delhi.

According to him, stent or bypass surgery is particularly considered when there are high-risk coronary blockages “that place a large amount of heart muscle in jeopardy, or when troublesome angina (chest pain) persists despite an adequate trial of medical therapy.”

At the IMA’s research cell in Kerala, convenor Dr Rajeev Jayadevan says stenting is not like repairing a blocked water pipe. “It is a complex decision that is personalized to the individual patient sitting before the doctor, guided by established scientific society guidelines, diagnostic findings and specialized medical training.”

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Is finding a blockage on an angiogram (imaging test of the arteries) enough to decide on angioplasty?
Not necessarily. “We consider how severe the narrowing is, whether it is actually reducing blood flow, the patient’s symptoms, the location and complexity of the blockage, and the overall clinical picture. In some cases, additional tests are required,” says Dr Balbir Singh, chairman, Cardiac Sciences, Max Healthcare.

Who should get an angiogram?

In patients with chest pain who are not having a heart attack, doctors first estimate the pretest probability or how likely the patient is to have significant coronary artery disease. “This estimate is based on factors such as age, sex, the nature of the symptoms and other risk factors, including smoking, family history and existing medical conditions. If the estimated probability is very high — above 85% — guidelines may support proceeding with coronary angiography. If it is very low — below 15% — further testing for coronary artery disease may not be necessary,” says Dr Akshay Ashok Bafna, HOD Cardiology at Rajarshi Chhatrapati Shahu Maharaj Government Medical College, Kolhapur.

What’s the reason for patient confusion?

Unfortunately, information asymmetry can limit a patient’s ability to make a truly informed choice. “Faced with an angiogram showing a 70% or 90% blockage, patients understandably depend heavily on their treating cardiologist to explain whether a stent is likely to prolong life, prevent a heart attack, relieve symptoms or add little to good medical therapy,” explains Dr Roy.

It is the overuse of stents in these situations that has, at times, brought an otherwise lifesaving treatment into disrepute. “This has in recent times been amplified due to wide availability of insurance schemes. Unfortunately, we have seen that it has at times led to an opposite and potentially dangerous consequence: patients refuse stents even during an acute heart attack, when timely angioplasty can save lives and preserve heart muscle,” he says.

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Dr Jayadevan concurs that a treatment that was clinically necessary can easily be perceived as unnecessary when viewed without the full medical context. “The complex factors leading to a specialist’s clinical decision are rarely known to an outside observer. Whenever there are specific concerns or apparent protocol issues, they should be investigated through appropriate statutory medical bodies and clinical audit forums, rather than through generalized public commentary. If public trust is eroded, the real tragedy is that people facing life-threatening heart conditions may hesitate to seek evidence-based scientific interventions, sometimes falling victim to unproven treatments,” Dr Jayadevan adds.

Dr S Ganapathy, surgeon and public health activist, points to another source of anxiety for patients: the difficulty of interpreting cardiac tests without the right clinical context. Even normal variations in an ECG can differ with age, he says. “An ECG of a 30-year-old is different from that of a 50-year-old,” he explains, noting that variations in ECG waves can sometimes add to a patient’s anxiety when they are not properly explained.

Such anxiety, he says, can make patients particularly vulnerable to inappropriate medical advice. “Some people can prey upon these anxieties,” he cautions, making it important for patients to understand that an abnormal-looking test does not, by itself, mean that an invasive procedure such as angioplasty is necessary.

Ask the right questions

Dr Bafna argues for precise framing of the question. Instead of asking “Is angioplasty necessary?”, the appropriate question should be, “Is angioplasty necessary for this particular patient, at this particular time, based on the available scientific evidence?”

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Patients, too, should be encouraged to participate in treatment decisions. “They should understand why a procedure is being recommended, what alternatives exist, what the expected benefit is, and what risks are involved,” says Dr Bafna.

The public messaging should not be to “avoid stents” but stent the right patient at the right time. “Greater public awareness, shared decision-making and audit of adherence to evidence-based indications are essential to achieving this,” adds Dr Roy.