To stent or not to stent?

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DEAR DR. ROACH: My regular cardiologist did a battery of screening tests (CT scan of heart, ultrasound of heart and abdominal vessels, stress test). Sure enough, one of the tests suggested blockages, and he said I should prepare to get an angiogram from an interventionalist to verify and possibly have stent(s) placed. My heart muscle still has no damage (I had quadruple bypass six years ago, even though I had no symptoms; I am 68, not overweight and have never smoked). Since receiving the news five weeks ago about possible blockages, I have exercised, eaten very well and have seen my blood pressure go back to normal and my lipid panel all come within normal range.

When I asked my regular cardiologist if having stents placed would prevent me from having a heart attack, he gave a resounding “yes,” it would. I have read that stents do not prevent heart attacks and are effective only if you have angina (I don’t) or are having a heart attack (I’m not). My older brother had stents placed, and they caused him so much trouble that they had to remove them. What is your take? To stent or not to stent? — J.T.

ANSWER: That is the question. The answer comes from the medical literature, pretty clearly for a change, and it contradicts what your regular cardiologist told you. Opening blood vessels, and keeping them open with stents, in combination with optimal medical management, relieves symptoms better but does not significantly decrease heart attacks and death rates compared with optimal medical management alone. There is an exception, as you identified: In an acute heart attack, stenting open the blocked blood vessel does decrease the rate of cardiac mortality. Otherwise, stenting is useful for improving symptoms that don’t respond to medical treatment, especially in a person with high-risk stress-test results, but not for improving risk of death or heart attack.

Any medical procedure can have untoward effects, and with stents, the biggest one is the stent closing (due to blood clots). I have never heard of cardiac stents being removed, since the innermost wall of the artery tends to grow around the stent, making removal dangerous or impossible except through surgery. I think your lifestyle changes of diet and exercise, along with your medical therapy, is doing you more good than stents would.

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DEAR DR. ROACH: I am 68 years old, and will be having bypass surgery soon. After my surgery, will L-arginine be good for my heart? I know I will be walking every day. — G.J.S.

ANSWER: L-arginine, an amino acid, has been shown to increase nitric oxide in blood vessels of people with high blood cholesterol and blockages in their arteries. There are two studies I know of that showed no effect from arginine on blood flow or inflammation. On the other hand, one study showed that supplements of arginine, along with phytoestrogens, B vitamins and vitamins C and E (as part of a medical nutrition bar) in people with angina improved some blood flow measurements and the ability to exercise on the treadmill. It also has been shown to have some benefits in people with heart failure.

Based on these studies, I don’t recommend arginine after cardiac bypass surgery. However, there may some benefit, and since it is unlikely to be harmful, I wouldn’t try to dissuade someone who wanted to give it a try.

The booklet on heart attacks, America’s No. 1 killer, explains what happens, how they are treated and how they are avoided. Readers can order a copy by writing: Dr. Roach — No. 102, Box 536475, Orlando, FL 32853-6475. Enclose a check or money order (no cash) for $4.75 U.S./$6 Can. with the recipient’s printed name and address. Please allow four weeks for delivery.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at P.O. Box 536475, Orlando, FL 32853-6475. Health newsletters may be ordered from www.rbmamall.com.

(c) 2014 North America Syndicate Inc.

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