Are coronary stents necessary?

Why in the News

The Kerala Chief Minister‘s remarks questioning “unnecessary” angioplasty have drawn objections from medical organisations, who fear the public will lose trust in doctors. Evidence shows most patients with stable heart disease do as well on medicines as with a stent, so the question is how much of India’s rising stent use is clinically needed.

What is a coronary stent, and when does it save lives?

1. What it is: Percutaneous Coronary Intervention (PCI) widens a narrowed heart artery with a balloon (balloon angioplasty) and a stent, a small mesh tube that props the artery open, like scaffolding.
2. Heart attacks: When an artery suddenly blocks, prompt angioplasty restores blood flow, saves heart muscle and improves survival. Time leaves no room for second opinions.
3. Persistent angina: Stents also relieve selected patients with persistent, activity-limiting angina, chest pain from a lack of oxygen-rich blood.
4. The takeaway: Stents save lives in emergencies, so the real question is which patients need one.

Why is a narrowing on an angiogram not enough?

1. Anatomy is not need: An angiogram, an image of the heart’s arteries, can show a narrowing. The image alone does not prove a stent is needed.
2. Basis for deciding: The decision must weigh symptoms, how severe the blockage is, how much it cuts blood flow, the overall disease pattern and expected benefit.
3. Stent is not a cure: A stent treats one narrowing, not atherosclerosis (fatty build-up inside arteries), so patients remain at risk and need continued preventive treatment.

What did the ISCHEMIA trial find?

1. Trial design: The ISCHEMIA trial (The New England Journal of Medicine, 2020) enrolled 5,179 patients with stable coronary artery disease and moderate to severe ischemia (restricted blood flow to the heart).
2. Two strategies: Patients got either an invasive strategy (angioplasty or bypass surgery) or optimal medical treatment, with procedures kept for an acute event or angina.
3. Results: After a median 3.2 years, and again after five, the groups showed no significant difference in cardiac arrests, hospitalisation for worsening chest pain or heart failure, or deaths.
4. Core lesson: Most stable patients do as well on medicines as those who undergo stenting or bypass surgery.

Is India’s stent boom driven by need?

1. Six-fold rise: National Interventional Council figures show annual PCI procedures in India rose more than six-fold.
2. Opposite US trend: United States (US) PCI procedures have fallen sharply, reflecting progress in prevention and treatment.
3. Not proof of overuse: A large population, much early-onset (premature) coronary disease, socio-economic progress and better access to cardiac centres explain part of the rise.
4. Need or incentive: The open question is how much of the rise is clinical need, and how much is doctors’ practice patterns, financial incentives or gaps in knowledge about medical treatment.
5. Neither blame nor blind trust: Most doctors act in patients’ interests, but no profession is immune to inappropriate practice.

Challenges

1. Procedure-linked earnings: Where hospitals earn per procedure, the financial pull favours stenting over long-term medical care.
2. Image-led decisions: Treating any narrowing seen on a scan as proof of need pushes stable patients towards procedures.
3. Trust in doctors: Blanket criticism of angioplasty can erode confidence in doctors, even for life-saving emergency procedures.

Way Forward

1. Guideline-based medicines first: Doctors should give every coronary patient optimal medical therapy: lowering LDL (low-density lipoprotein) cholesterol, anti-platelet drugs, blood-pressure control, diabetes management and lifestyle change.
2. Second opinion for stable cases: Hospitals should offer stable patients a second opinion before any planned stent.
3. Outcome-based audit: Health authorities should judge cardiac care by lives saved and timely, affordable treatment, not volume.

Conclusion

India’s stent debate is about matching a proven procedure to patients who need it, not condemning cardiologists. Whether stable patients are offered medicines first, and care judged by outcomes rather than volume, remains unresolved.

Key numbers

1. Annual PCI procedures in India: about 1,13,000 (2008) to more than 7,26,000 (2024).
2. ISCHEMIA trial scale: 320 sites in 37 countries.
3. US PCI procedures, 2003 to 2016: down about 40%.

Government Initiatives on Non-Communicable Diseases

1. National Programme for Prevention and Control of Non-Communicable Diseases: Covers diabetes, hypertension, cancers, stroke and severe heart attacks, screens everyone over 30, and runs 233 Cardiac Care Units.
2. India Hypertension Control Initiative: Run by the Indian Council of Medical Research, the Health Ministry and the World Health Organization, it promotes standard treatment protocols and follow-up.
3. Pradhan Mantri Jan Arogya Yojana: Covers hospital care for non-communicable diseases, including cardiac stents and surgeries.
4. Ayushman Arogya Mandirs: Formerly Health and Wellness Centres, they provide primary care, including screening for non-communicable diseases.

Matching Previous Year Question

“No direct PYQ traced in the provided files. Thematic PYQ: [2021, GS2, 10 marks] “Besides being a moral imperative of a Welfare State, primary health structure is a necessary precondition for sustainable development.” Analyse.(150 words)”