Re: Stenting

These are very extreme views. I find it hard to reconcile what R Pierce
Butler is saying with modern cardiology practice.

For starters:
1. In my hospital I work on the basis of 2%-5% false positives or
negatives for nuclear stress tests. There are many studies reporting
over 90% sensitivity & specificity. We seem to do better than that.
It's exceedingly rare, for example, for someone with an abnormal
thallium scan to turn out not to have an anatomically-appropriate
lesion on follow-up angiography. Stress echo, when well done, is about
the same.

2. There is no prep for a nuclear stress test, unless it's a
Persantin / adenosine (non-exercise) version, when caffeine is excluded
for 24 hours. We don't ask people to skip breakfast. Certain
medications may need to be stopped.

3. As far as the non-exercise, or chemical version goes: A Persantin
(dipyridamole) test sometimes makes people feel unwell because of BP
fall, but I've hardly ever had a patient complain about an adenosine
scan, and in any case symptoms from this cease within a few seconds of
stopping the infusion.

4. Testing to exhaustion is not part of a normal diagnostic protocol.
I've only ever seen that in gung ho physical performance evaluations
("executive health checks"). Diagnostic testing is heart rate or
symptom-limited. If you test to exhaustion in asymptomatic people, then
yes, of course you will generate false-positives, and no, you don't
learn anything new. I don't know what value it has other than as a
confidence-building exercise for some people.

5. Clopidogrel (e.g. Plavix) for life is not standard practice after a
drug-eluting stent. One year, maybe a little longer. Some people have
recently expressed the view that it should be taken for longer periods,
but it rarely is. Side-effects from clopidogrel also have been rare in
my experience (unless you have to undergo unexpected surgery, when
there certainly are additional bleeding risks.)

6. Recovery rate after CABG is prolonged in octogenarians - may take
a year before they're back to where they were - but it can be very fast
in people in their 50s and 60s. Plenty of these folk are back at work
in a month. A lot depends on how the early post-surgery period is
managed - rapid removal of the endotracheal tube (within a couple of
hours) greatly speeds up the process, and use of all-arterial grafts
(i.e. no leg veins) eliminates the mobility problems.

I confess to being confused myself as to why the OP (dayb_) is
confused. The multiple options listed seem to be the same options that
face all of us whether we've had stents, symptoms, heart attacks, or
just plain nothing at all so far (waiting for the blow, Woody
Allen-style). I think you have to count on it that stenting (PCI) in
the elective or non-acute situation doesn't do anything but relieve
symptoms, although it's very good for that. Most heart attacks occur
from a lesion that arises acutely in a place that did not warrant a
stent 10 minutes earlier. And long-term angiogram follow-ups have shown
that if there is further deterioration, it has usually happened at
places in arteries which were not the ones that looked like they could
be stented at the time of the original angiogram. So what would be the
point of stenting moderate narrowings that are not currently causing
trouble?

David Rollo
Cardiologist, Melbourne Australia

.