Do you need a stent? Here’s what you need to know

My specialist says I might need a stent, but will it really help me?

A: Doctors are, to quote Leonardo da Vinci, “disciples of experience”: they follow the evidence presented to them by their own eyes. If they do something and a patient gets better, they deem that something to have been successful. But they’re also fallible.

Which brings us to a small device known as the cardiac stent. What is it? Well, if you’re having a heart attack – a blockage in one of the arteries that supply blood and oxygen to the heart muscle – doctors can widen the artery using a balloon. To keep it open, they insert a permanent metal tube, called a stent. Life-saving, right?

Absolutely, but here’s the thing: half of them might be going into patients who don’t actually need them. If you’ve got tatty coronary arteries, you might experience chest pain caused by insufficient oxygen reaching the heart muscle. If the pain comes on with exertion and subsides with rest, that’s called “stable angina”. Treatments such as aspirin, anti-cholesterol pills and a drug to reduce blood pressure are proven to reduce your chance of a heart attack. Inserting a stent as well – according to a 2007 study called COURAGE – doesn’t shorten those odds. And yet doctors are continuing to put stents into patients with stable angina at the same rate, a UK study revealed last year.

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So what happened to evidence-based medicine? “The cardiologist and the patient look at the X-ray image, see a tight narrowing of the artery and say, ‘We’re sitting on a time bomb,’ ” explains Professor Garry Jennings, cardiologist and chief medical adviser at Australia’s National Heart Foundation. “Then they see pictures after the stent and it looks like a healthy artery.”

But tattiness tends to be an all-over condition. Unblock one artery and another can be problematic. This is why medication, plus lifestyle changes, are so effective: they improve the whole tree of vessels.

Stents can ease chest pain, but ORBITA, a 2018 study, made headlines when it showed that a placebo effect might be responsible. In the same year, Australia’s Cardiac Clinical Services Committee (CCSC) recommended stents only be used in stable-angina cases if medication had failed to work. In 2021, however, the Medicare Benefits Schedule Review Taskforce rejected that advice, reportedly after lobbying from cardiologists.

Stents continue to be used even when there’s no financial incentive for surgeons to insert them, such as in the UK’s NHS. “Clinical studies are the benchmark in terms of evidence, but…results are always open to different interpretations,” says Jennings.