Sudden cardiac death after stenting

Dear Dr. T,My father recently passed away one week before his 67th birthday in January 2013. He has always been a very healthy individual throughout his entire life with a strict diet, no junk food, regular exercise, and didn't smoke, drink alcohol, or do drugs. Very healthy person. He was a college professor with a PhD degree and owned a small business. Indian-American descent. He was very happy, lighthearted, and always cracking jokes and smiling. No one in our entire or extended family has ever had any kind of heart disease, or heart problems, so this was a surprise.Suddenly, he had 3 heart attacks all within one month in October 2006. Left Anterior Descending (LAD), Circumflex (Circ) and Right Coronary Artery (RCA) were all blocked and he had 3 stents put in immediately. He was doing very well and put on a plethora of medications, lipitor, metaprolol, plavix etc and many others. His heart and ekg's, troponin levels, etc all were constantly monitored.In summer 2011 he had all three stents replaced I believe and was doing very well. So from 2006 - 2013 he was doing absolutely great with regular checkups. The DAY before he died, he went to the cardiologist and he checked his heart, did all the battery of tests, and the cardiologist said the heart looked wonderful and was functioning very well, no blockages, no need of a bypass or anything like that. My father was very happy.The next morning, he told me he had chest pains and lost consciousness and died a few minutes later. Paramedics, ER docs, cardiologists, surgeons everyone tried everything for 1 hour straight, shocking him continuously, but it was no use. I am shocked how this can happen 12 hours after such a positive cardiologist appointment. On the death certificate, I see that he did not die from a heart attack, it was an electrical wiring problem. The ER doc wrote that he had ventricular fibrillation ----> left ventricular systolic dysfunction. The ER doc wrote that it was due to advanced coronary artery disease.Can you explain what could have happened here, and why so suddenly, seemingly out of the blue? How can one have such a great cardiologist appointment, but die of SA/AV node failure the next morning? Why didn't that show up in the lab reports? I'm a medical student and would like to know. My dad died a week before my USMLE exam.Thanks, 

I am so sorry to hear about your father's death. Re: what caused what in what order - this is the sequence:

  1. Atherosclerosis caused
  2. Coronary Artery disease with progressive disease  complicated by
  3. A major Myocardial Infarction causing
  4. Ventricular Fibrillation and
  5. Sudden Cardiac Death

Thus I disagree with the final diagnosis on the deatth certificate.

The "battery of tests" on the preceding day most likely did not include a stress test or CTCA since your father was asymptomatic. I suspect they would have shown a major stenosis. These are the options of what could have happened:

  • Stent thrombosis
  • New disease:
    • Local disease at or near one of the stented arteries
    • A new Left Main coronary artery stenosis during the interval, rather than a recurrence in one of the previously stented arteries.

While stenting is of course not responsible for the Atherosclerosis, it causes severe local damage to the artery involved; the result an inflammatory reaction that involves the area that is stented as well as a zone up - and down stream of the artery, thus the 10-15% yearly failure rate/stent.

In essence a stent produces a new disease and to prevent the built-in complications, all those drugs are given to suppress the inflammatory response. An acute event is usually the result of plaque hemorrhage with acute occlusion of the artery involved, which is what probably happened. He died before an examination of the heart would have shown actual necrosis. 


There are many articles (and I have reported on them many times) showing stents do not protect against future heart attacks or prolong life, as opposed to bypass surgery (CABG), which has much superior results in patients with 3-vessel CAD such as your father.

In contrast, if your father had been treated with bypass surgery (CABG), I am 99% certain he would be alive today (accounting for a <1% operative risk in a healthy male patient with normal heart function - similar to the risk of stenting).The following Kaplan Meier survival analysis was done on my patients during the period 1986-2001 with almost 200 months follow-up:

The upper curve shows the long term (193 months) survival in CABG using a Left Internal Mamary Graft (LIMA): 94%, the operation your father would have had. The lower survival curve reflects an 86% long term survival, including all other cardiac operations.

Although the literature has associated CABG with a higher risk of stroke than PCI, this was not at all the experience in my practice.

Even so, almost all literature confirms my opinion of a superior outcome with CABG, especially in patients with 3-vessel disease, diabetes and or diminishe heart function.

An important issue in the therapy for multivessel or left main CAD is that of re-intervention due to stent restenosis or graft occlusion. Although failure rates of the initial revascularization procedure were found to be not significantly different for PCI and CABG in the SYNTAX trial, the consequences of the two respective events are known to differ enormously.

While stent thrombosis frequently results in myocardial infarction (up to 80% of cases) with reported mortality rates between 30 and 45%, graft occlusion usually becomes apparent with recurring angina, which then leads to repeat revascularization. This effect is well known from the literature and did indeed translate into increased rates of myocardial infarction and cardiac death in the PCI group of the SYNTAX trial:

“CABG remains the standard of care for patients with three-vessel or left main coronary artery disease”(2)

In summary:

Patients with extensive (“3 vessel”) disease that may include a “Left main stenosis”, diminished heart function and/or diabetes do much better with a bypass operation. In situations where time is of the essence, such as an acute heart attack, a stent may the best option if treatment is quickly enough (w/i 8 hrs of the event). The same is probably also true for patients with only “one or two” vessel disease, although there are mini bypass operations that offer an equal if not superior treatment because it promises a much better long term protection.

Hope this helps. I also hope your USMLE exam went well despite this sudden terrible loss of your father,

Dr T

1. Best way to revascularize patients with main stem and three-vessel lesions. Patients should be operated! H. Reichenspurner et al, Clin Res Cardiol 2010 Jul 9

2. "CABG remains the standard of care for patients with three-vessel or left main coronary artery disease" (Serruys et al. in N Engl J Med 360:961-972, 2009).

3. Pathology of acute and chronic coronary stenting in humans. - Farb A - Circulation - 5-JAN-1999; 99(1): 44-52


I am sure these findings were correct. If indeed your dad died of cardiac causes and f.i. a massive pulmonary embolism, the cause of death is more likely related to what would have better protected him. When I wrote: "There are many articles (and I have reported on them many times) showing stents do not protect against future heart attacks or prolong life, as opposed to bypass surgery (CABG)", I tried to explain that repeat or primary stenting in three vessel CAD is not the optimal treatment in most patients (particularly those who are otherwise good candidates for bypass surgery). Most cardiac surgeons agree that to stay alive with CAD, all you need is a patent LIMA to the LAD, because it never fails as the survival data in my graph confirmed.
Thus if an error was made, it was in the decision to perform repeat stenting years ago. Acute occlusion of a major artery due to plaque rupture is far more likely after stent placement than after CABG because of the severe local damage that occurs.
Since you are getting to the end of your medical school education, soon you will be exposed to the responsibility of making clinical decisions that may have far-reaching and sometimes lethal consequences for your patients. This sad sequence of events was one of them.
I'll be glad to discuss this further in private.
Hope this helps,
Dr T

He was seeing his cardiologist every 4 months. The cardiologist said his heart looked great, no need for bypass, and that he didn't have to come back for another visit for ONE YEAR. That's how good his heart looked. Then he died the next morning. Do you feel the cardiologist royally screwed up and it's his fault? Or this soft plaque thing came out of the blue?

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