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Pastimes : The Justa and Lars Honors Bob Brinker Investment Club Thread

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Jan 28 4:00 PM EST

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To: Kirk © who wrote (5637)	9/30/2010 7:13:39 PM
From: marc ultra	3 Recommendations Read Replies (2) of 10065

< What do you think of the studies or reports that show getting a stent more than maybe 15 hrs after a heart attack does little good for anyone but hospital and MD's bottom line? I think you have to distinguish between reasons why someone is getting a stent. In the case of ACS (acute coronary syndrome like an MI), angioplasty with stenting is done emergently to try to maintain or restore blood flow to ischemic heart muscle and thus limit the amount of heart muscle that may be damaged. This should be done within a certain window of time to be beneficial. The situation you bring up I think can be divided into two groups. One is if someone has an MI but doesn't present until more than 12 hours later and is relatively stable at that point. I believe the latest literature suggests angioplasty and stenting at that point may not be beneficial. A second situation which is very common is where someone is having some fairly stable symptoms of angina and on cardiac cath is noted to have significant blockages in one or more coronary artery. To look at this I think we have to look at what causes a heart attack. The old idea was that plaque builds up and eventually occludes a coronary artery leading to an MI. If that were true then it would make sense to go and do angioplasty and stenting on everyone with significant plaque blockage in their coronaries. We know now though that is usually not the reason for an MI. Instead really plaques of various sizes including relatively small ones can become unstable and if one ruptures a clot can form and it is the clot that obstructs blood flow and leads to an acute MI. Also coronary plaque in general is more of a global disease so it's not like like everything else is perfect except for that one stable blockage. That being the case just trying to open up stable blockages probably doesn't do much to prevent heart attacks. The situation where that comes up is where people have stable angina like chest pain with exertion due to some degree of blockage. So that could either be treated with medicines or you can do an elective angioplasty with stenting. While that can relieves angina symptoms, because that blockage per se is not generally what causes a heart attack you're not necessarily preventing an event by opening it up like that though I think people tend to think this is doing more than it really is. There also can be complications from stenting like clots forming and that can be deadly so it's not a benign procedure and anticoagulants of some type are also used with it. So we have two situations here that warrant consideration of how much angioplasy with stenting should be used. One is the point you mention of someone presenting more than 12 hours after an acute MI and if they're stable you are probably correct in the idea they do little good. The other one is this stable angina with stable coronary blockages and how much that should be treated with stenting versus just meds which do things like increase blood flow to or decrease the demand for oxygen from the blood to the heart. I'll throw in the caveat I'm not a cardiologist and I'm not currently practicing so I'm not up on all the latest literature. Also this is the situation in general but individual cases can have their own details which favor stenting or not.

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