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Cardiologists are putting in stents needlessly, doctors say

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f739 (Published 04 February 2013) Cite this as: BMJ 2013;346:f739
  1. Soumyadeep Bhaumik
  1. 1Kolkata

Cardiologists in India have been accused of cashing in on the rapidly increasing incidence of coronary heart disease there by recommending stenting and other invasive coronary procedures to patients who may not need them.

A report by Global Industry Analysts says that the worldwide market in coronary stents is predicted to reach $1.8bn (Rs96bn; £1.1bn; €1.3bn) by 2017.1 With the death rate from coronary heart disease rapidly falling in developed nations, much of the burgeoning market for stents is due to increasing demand from India, which has one of the world’s highest rates of death from coronary heart disease.2

Concern is growing in India that cardiologists are carrying out angioplasty and putting stents into patients who are unlikely to benefit from the intervention. In January a cardiologist in south India was arrested for allegedly taking a bribe from a stent manufacturer.3

In 2010 the Central Bureau of Investigation started probing allegations of a coronary stent scam involving several corporate hospitals and the staff of the Central Government Health Scheme in Hyderabad.4

“Patients widely believe that angioplasty saves lives and abolishes [the risk of] future heart attacks, which it does not,” said S P Kalantri, of the department of medicine at the Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra.

He continued, “Most cardiologists in India do angioplasties on patients with chronic stable coronary artery disease without trying to stabilise them with intensive medical therapy. Also, most patients are not informed about the pluses and minuses of angioplasty and the merits and adverse events associated with different types of stents.”

The Choosing Wisely campaign of the American College of Cardiology states, “Stent placement in a noninfarct artery during primary PCI [percutaneous coronary intervention] for STEMI [ST-segment elevation myocardial infarction] in a hemodynamically stable patient may lead to increased mortality and complications. While potentially beneficial in patients with hemodynamic compromise, intervention beyond the culprit lesion during primary PCI has not demonstrated benefit in clinical trials to date.”5

Rakesh Biswas, professor of medicine at the People’s University of Bhopal, spoke to the BMJ on similar lines when he affirmed the role of stenting in life threatening cardiogenic shock and also its role in refractory chronic cardiac chest pain (where it is used along with angioplasty) for short term relief.

But he added, “However, in my experience coronary arteriographies and revascularisations with stenting are often done where the above indications are absent and patients are actively encouraged to undergo stenting as if it would permanently cure the patient.

“One needs to understand that stenting is a temporary fix for a local obstruction in the coronary pipes and does not guarantee that the patient will not suffer from another heart attack due to blockage in another part of the same vessel.”

Biswas believes that the practice is “fuelled by corporate greed that makes a business out of glamorising health issues that may have been tackled using less invasive means.”

Kalantri added, “Cardiologists start practising at the age of 35 in the private sector, have huge loans to pay, and have to compete with their colleagues who are all too eager to perform angioplasties and deploy stents for reasons which are not always evidence based.”

Biswas believes there is a need for systematic evaluation of the allegations of overuse.

Notes

Cite this as: BMJ 2013;346:f739

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