To stent or not? New study makes decision easier for certain heart patients

By Deborah Kotz, Globe Staff

Heart disease patients who experience regular bouts of chest pain -- that’s not an emergency situation like a heart attack -- often are faced with deciding whether to have angioplasty along with a stent to prop open their blocked artery or to stick with just medications such as beta blockers and a cholesterol-lowering statin. But a new study published online by the New England Journal of Medicine may help make the decision easier for doctors and patients.

It found that those who had a minimally-invasive test called fractional flow reserve to measure blood flow in the blocked artery had a better outcome from stenting with medications than when they chose medications alone, that is, if the test revealed that the artery wasn’t functioning properly and that the blockage might eventually lead to a heart attack.

In fact, the trial was halted early after less than two years because the results were so striking: About 4 percent of patients who had stents placed based on their poor results on the fractional flow reserve test wound up with a serious complication like a heart attack or being hospitalized to have an emergency angioplasty with stent placement, compared with nearly 13 percent of those with a poor result on the test who were randomly selected to remain just on their medications.

“Fractional flow reserve testing is massively underused,” Belgian study author Dr. Bernard De Bruyne wrote me via e-mail. It should be, he added, “the gold standard” way to assess patients who are on the fence about whether to have a stent placed in their artery.

Whether the results lead to an increase in stent procedures -- which have been on the decline ever since studies found that they don’t decrease death risk in stable heart patients -- remains to be seen.

“It will be interesting to see whether it does,” said Dr. Patrick O’Gara, medical director of the cardiovascular center at Brigham and Women’s Hospital. “We already use the test at the Brigham,” he added, especially in those whose arteries are moderately blocked -- about 70 percent -- as opposed to those with severe blockages of 95 percent, where stenting clearly helps to relieve their chest pain.

He also noted that there’s still no evidence that stents placed in stable heart disease patients reduce the risk of dying. (There weren’t enough patients in the new study to conclude that the slight difference in death rates was statistically significant.) While a stent can reduce deaths in those having a heart attack, it’s mainly beneficial for the short-term relief of chest pain, breathlessness, and other heart symptoms in those with low-risk disease.