Patients overestimate benefit of heart stents, study says

Health specialists said they understand why patients might overestimate the benefit of heart stents. Cancer patients, for example, may believe chemotherapy will destroy a tumor, counting on a cure when medical evidence can’t promise that.

Heart patients are faced with a high-risk disease and a high-tech treatment that seems impressive, said Dr. Eugene Rich, director of the Center on Health Care Effectiveness in the Washington office of the research group Mathematica. And the idea of closed arteries being bad and opened ones being good is easy to grasp.

“We all would prefer a simple, straightforward, one-time solution to our health problems,” he said.

Easing chest pain in these patients isn’t a bad thing, so misunderstanding the benefits of stents wouldn’t technically be called overuse, Rich said. But like any medical treatment, the procedures carry some potential for harm.

“There’s a likelihood that patients are getting procedures that they would have chosen to not get if they knew better," he said. "I think that’s a different understanding of ‘overuse.’ "

In the Baystate study, researchers surveyed 153 patients who had agreed to have angioplasties, in which a balloon-tipped catheter is threaded through an artery in the leg to reach narrowed blood vessels near the heart. The balloon is inflated to open blockages and a mesh tube called a stent can be inserted to keep the blood vessels clear.

The researchers wanted to know whether the patients thought the procedures could prevent death or heart attack. They posed the same question to 27 cardiologists who had either referred the patients to Baystate or performed the procedures there themselves. More than 80 percent of patients believed their chances of having a heart attack or dying from a heart attack would go down if they had the procedure.

Most of the cardiologists said the opposite. In line with a watershed clinical trial published in 2007, more than 80 percent said they believed that angioplasties and stents only alleviate chest pain in these patients. Opening up blocked coronary arteries can be life-saving in emergencies, but there is no evidence that increasing blood flow to the heart in stable patients does anything more than help them feel better.

The Baystate paper asks why doctor and patients were so far apart. During the informed consent process, doctors explain what both the risks and benefits of a treatment may be, as well as alternative treatments, including doing nothing. The researchers didn’t observe those conversations, so they couldn’t say whether patients were told what the procedures can and can’t do. Nor could they say whether the patients should have undergone the procedures or used medications alone.

“We were not looking at what is appropriate or inappropriate. We were looking at a simple question: What physicians think they told patients and what patients think they’ve heard,” Schweiger said. “We have a lot more work to do to figure out what the best way is to get accurate information to patients so they understand it.”

Patients are not to blame for the misunderstanding about angioplasty and stents, said Dr. Michael Pignone, a medical editor for the Boston-based Foundation for Informed Medical Decision Making and a professor at the University of North Carolina School of Medicine.

“The onus is on us as health care professionals to really drill down to what is the essential information,” he said. “We need to learn from patients what is the most important information to them.”

Dr. Christopher Cannon, a cardiologist at Brigham and Women’s Hospital, worries that patients may mistakenly think that getting a stent means they can go off their heart medications, including statins to lower cholesterol and aspirin to dampen inflammation.

“That’s the disconnect. People think the procedure is going to save them,” he said. “Stopping medications is a recipe for disaster.”

There’s a larger cost to society, too, Pignone said. “Heart disease is a huge health problem and we spend a ton of money treating it," he said. "Some of it may not be as well spent as it could be.”