Important Information About the Risk Calculation
- The risk results shown in this program are estimates.
- The results show your current potential risks & benefits of this treatment option. However, this result is not an actual prediction. It will only give you a general idea of your future risk with this option.
- Your actual risks may or may not be the same as the estimates shown. This program shows the estimated health risks of people with your same age, gender, and risk factor levels. Every person is different. Your current health status, your medical history and the traits you inherited from your family make you unique. This program is not meant to provide medical or other professional advice. Talk with your doctor or other healthcare professionals for information specific to you and for advice in making final decisions on managing your care and improving your health.
The results of this questionnaire indicate that patients like you may benefit from a Percutaneous Coronary Intervention (PCI), also called Angioplasty or Stent. If successful, a PCI will improve or restore the bloodflow to your heart. Remember that the disease process, atherosclerosis, which causes blockages in your coronary arteries will not change with this procedure and will require continued treatment. Your specific situation may well require a different recommendation that will depend on factors that cannot be evaluated here. Any procedure has distinct consequences that you should consider before agreeing to undergo an intervention.
There are some other factors that you need to know about, which may help you make the best decision in your own care:
What are the risks and benefits of a PCI procedure?
Let’s start with the benefits;
A straightforward PCI provides a rapid, less invasive option for management of a blocked coronary artery with quicker hospital discharge and return to daily activities in comparison with a Coronary Artery Bypass operation. A PCI can be performed in a short period of time, and if successful you could be back home with the blood flow to your heart restored back to normal. A PCI is particularly helpful in the treatment of an acute heart attack, where it can restore blood flow (and thus prevent damage to your heart muscle) much quicker than a bypass operation, at a time when speed is of the essence. More than 80% of stents used in the US are Drug Eluting Stents (DES), that have reduced the risk of closure from about 30% to around 10%.
Below is an animation of how this works (From: Primary PCI for Myocardial Infarction with ST-Segment Elevation. Ellen C. Keeley, M.D., and L. David Hillis, M.D., NEJM Volume 356:47-54, Jan 4, 2007):
If you have only one or two blockages and your heart function is excellent, the outcomes for surgery and PCI are equivalent, with PCI’s advantage of a much less involved procedure. However, PCI has a significant disadvantage in that it is likely you will need an additional procedure within the next year. You also may be a candidate for medical therapy in combination with lifestyle modifications without having to go through an intervention.
Now the Risks:
It is important to understand that outcomes differ based on the total number of diseased vessels, or as what appears to be the case with you, that all arteries can be “stented”. Each time another stent is placed, the risk that something may go wrong is repeated. If multiple stents are needed to unblock one artery, it increases not only the risk of failure (and other complications), but also the possibility of blocking off side branches and creating a “highway without exits”. This is a major difference with coronary bypass surgery where multiple bypasses are performed with no increase in risk. A PCI destroys the artery locally and cannot be operated there ever again. If lots of stents have been used, it may become difficult to perform a bypass to that artery. A lot of doctors will tell you that a PCI will avoid a potentially dangerous and painful Coronary Artery Bypass procedure, and that it can always be done at some point in the future. However, a number of studies have shown that after multiple PCIs the heart function slowly worsens over time, which also will make a bypass procedure more risky when that procedure becomes necessary.
Successful placement of a stent depends on a number of factors. Is the blockage described as “complex”? If so, you may have a high “risk score” and be a better candidate for a bypass operation than PCI.
Here is a list of potential complications:
The main complications of balloon angioplasty and stenting are
- Restenosis (recurrence of the blockage)
Thrombosis causes complete blockage and may occur at any time:
- Acutely (immediately during or after the procedure)
- Subacutely (within 30 days)
- Late (> 30 days)
Restenosis does not occur until several weeks after the procedure or later; it may cause partial or, less commonly, complete vessel blockage.
PCI with balloon angioplasty alone (without stent placement) has the following:
- A Risk of acute thrombosis of about 5 to 10%
- A Risk of subacute restenosis of about 5%
- An overall restenosis rate of about 30% to 45%.
- The use of stents has almost eliminated the need for emergency coronary artery bypass grafting following PCI
PCI with stenting:
- A Risk of acute and subacute thrombosis or restenosis of < 1%
- With Bare Metal Stents (BMS), a risk of late restenosis that is decreased to 20% to 30%
- Drug Eluting Stents (DES) lower the late restenosis risk to about 10%. However, using a DES increases risk of late stent thrombosis, about 0.6%/yr up to 3 years.
Complications besides restenosis are similar to those of coronary angiography, although risk of death, Myocardial Infarction (heart attack), and stroke is greater. Of all angiographic procedures, PCI has the highest risk of some degree of kidney failure due to the use contrast; this risk can be reduced by hydration. Stenting, in addition to the above, may cause complications of bleeding secondary to aggressive adjunctive anticoagulation (blood thinning), side branch occlusion, and stent embolism. Below is a link to an animation of how stent occlusion may occur:
(From: Editorial from The New England Journal of Medicine: Curfman GD et al. Drug-Eluting Coronary Stents — Promise and Uncertainty. NEngl J Med 2007;356:1059-60).
If a stent procedure is offered, will it be the best one out there?
Stent technology is constantly changing. What is recommended today may be suboptimal tomorrow. There is huge competition between the various stent manufacturers and they go to great length to place their products on the market, which includes “for-profit” marketing to hospitals and physicians. Not only is stent technology constantly changing, but the drugs that “drug eluting” stent coils leach into the blockage are different from one product to the next. Wouldn’t you want to know that your stent is the best one, not only now, but 10 years into your future? Often, the relevant literature doesn’t look that far ahead, even if not biased towards the sponsoring company (95% are!). Resulting recommendations have a very limited value.
If a Stent procedure is offered, will it be in the best hospital with my Cardiologist well qualified?
Look for a hospital with a long history of performing stents and a Board Certified Cardiologist. Outcomes are closely related to experience. It is possible to obtain outcome information on both hospitals and individual cardiologists, but make sure you also inquire about things as length-of-stay and infection rates and not least, the team of nurses PAs etc. that will take care of you! Here is a list of the the highest ranked hospitals in the US.
What are my chances that more than one stent is needed or that a repeat procedure is needed within the next year or so?
This all depends on how many blockages you have and how many arteries are involved. A PCI works best in a large artery with a blockage that is “not complex”. This means that the best results are achieved if no side branches are involved, in an otherwise healthy artery. Just like there are technical reasons that make a PCI more difficult, so there are similar reasons for Bypass surgery. It is thus important that your doctor explains your situation in detail, and especially what his plans for future treatment are.
In a study published January 24, 2008, in the New England Journal of Medicine. Edward Hannan and co-workers of the School of Public Health at the University of Albany, reviewed outcomes for 9,963 patients who received drug-eluting stents (DES) and 7,437 patients who underwent CABG between October 1, 2003, and December 31, 2004. It showed a high repeat procedure rate after DES; 30.6% of patients had repeat procedures within 18 months (approximately one-third of these may have been planned staged procedures). This compares to a 5.2% repeat procedure incidence after CABG during that same period. Only a small portion of these repeat stent procedures were related to the initial blockages, implying that repeat procedures are primarily needed for progression of disease elsewhere, not restenosis of the stented blockage. Stenting treats isolated stenosis, and progression of disease elsewhere, even in the same vessel, may require another procedure. CABG bypasses the current stenosis and the proximal two-thirds of the coronary artery where most future blockages occur, giving CABG a theoretical advantage over stenting, even if new stents are developed with no restenosis and no thrombosis.
What are the costs involved, not only now, but over the next few years (including the costs of medications)?
Other stent procedures are not only expensive (about $5000 in professional fees and $25,000 in hospital charges), but will disrupt your life every time for the period leading up to it, and of course afterwards (think also of the economic impact of being disabled again and again). Every procedure has its own associated risks and benefits. This includes the risk of dying. Every time a procedure is performed you run that risk again, a risk that is actually slowly increasing with time: “Stenting” often causes some atherosclerotic material to come loose and cause heart damage downstream.
However, please understand that no treatment available today will cure your heart disease. This means that no matter what else, you will continue to have to take medications and modify your lifestyle (exercise, diet, stop smoking, etc.)