Opinion
LESS IS MORE PERSPECTIVE
Yanling Yu, PhD Applied Physics Laboratory, University of Washington, Seattle.
Editor's Note page 321
Corresponding Author: Yanling Yu, PhD ([email protected]).
Do I Need a Stent? Choosing Medical Care Wisely Nine years ago at the age of 71, my mother was living an active life after retirement and enjoyed gardening, sewing, practicing tai chi daily, and working part-time in a fabric store. She was taking blood pressure medication to control hypertension. She began to experience brief episodes of chest discomfort when she walked uphill. I encouraged my mother to visit her family physician, and we learned that her blood pressure was elevated more than usual and her cholesterol and triglyceride levels were high. The physician recommended a treadmill test. During the test, she felt chest discomfort, although the symptoms went away within a few minutes. The physician recommended a thalluim stress test to see whether the coronary arteries were narrowed. A caring physician assistant explained the risks and benefits of the test and patiently answered all our questions, and my mother signed the informed consent. The test showed that her heart was receiving good blood supply at rest but supply was reduced at peak exercise, which was explained to us as consistent with a diagnosis of reversible ischemia. The result suggested a possible blockage and that my mother was at risk for a myocardial infarction. Soon, my mother was in a cardiologist’s office. The cardiologist asked a lot of questions about her medical history. He recommended angiography to verify the blockage and to see how extensive it was. He also suggested a stent at the same time to allow adequate blood flow to the heart. My mother and I asked a lot of questions about the risks. The cardiologist explained that the most significant risk was the formation of scar tissue that could narrow the artery and block blood flow again. My mother would need to receive long-term blood thinning medications such as warfarin to prevent blood clots. There were other rare but real risks, such as stroke, bleeding, and coronary artery damage. Finally, my mother asked, “Do I need a stent?” I knew my mother—she was weighing her options. The cardi-
Published Online: January 13, 2014. doi:10.1001/jamainternmed.2013.13479.
ologist could not tell for sure without angiography to see how serious the blockage was. My mother said it would be hard for her to make a decision when she is on the table during the middle of the procedure. Detecting my mother’s hesitation, the cardiologist suggested that she sign an informed consent before the procedure to authorize a stent and assured her that it would reduce the risk of a heart attack. I could sense that my mother was becoming increasingly uncomfortable about consenting to a stent when she was still unsure. I suggested that we learn more before she made a decision, so she asked about treatment options. After the physician discussed noninvasive options such as using a statin drug, my mother respectfully declined an angioplasty and a stent and decided to stay on the conservative side. We were thankful that the cardiologist did not pressure her. He prescribed a more effective antihypertensive medication and a statin to help lower cholesterol and triglyceride levels. She decided to modify her diet and lifestyle. At the end of the visit, he encouraged my mother to come back for an angioplasty if she changed her mind. At home I read more about angioplasty and stents. The medical literature says that the common complication of restenosis can happen in as many as 30% to 40% of cases, plus blood clots, which can in fact increase the chance of myocardial infarction.1 After more discussions about these risks, my mother reconfirmed her decision to decline placement of a stent. Nine years have passed, and my mother is doing well, living independently and enjoying life. She does not regret her decision to decline the angiogram and stent. During her annual checkup with her new cardiologist, her cholesterol and triglyceride levels were found to be under control. The physician encouraged my mother to keep up her good work by maintaining her healthy diet, regular exercise, and use of the right medications. Now, my mother is on another mission to try to eliminate the need for the statin.
1. Coronary Angioplasty and Stents. Mayo Clinic website. http://www.mayoclinic.com/health
/angioplasty/MY00352/DSECTION=risks. Accessed November 15, 2013.
Conflict of Interest Disclosures: Dr Yu is a member of the board of Washington Advocates for Patient Safety.
320
JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
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LESS IS MORE PERSPECTIVE
Yanling Yu, PhD Applied Physics Laboratory, University of Washington, Seattle.
Editor's Note page 321
Corresponding Author: Yanling Yu, PhD ([email protected]).
Do I Need a Stent? Choosing Medical Care Wisely Nine years ago at the age of 71, my mother was living an active life after retirement and enjoyed gardening, sewing, practicing tai chi daily, and working part-time in a fabric store. She was taking blood pressure medication to control hypertension. She began to experience brief episodes of chest discomfort when she walked uphill. I encouraged my mother to visit her family physician, and we learned that her blood pressure was elevated more than usual and her cholesterol and triglyceride levels were high. The physician recommended a treadmill test. During the test, she felt chest discomfort, although the symptoms went away within a few minutes. The physician recommended a thalluim stress test to see whether the coronary arteries were narrowed. A caring physician assistant explained the risks and benefits of the test and patiently answered all our questions, and my mother signed the informed consent. The test showed that her heart was receiving good blood supply at rest but supply was reduced at peak exercise, which was explained to us as consistent with a diagnosis of reversible ischemia. The result suggested a possible blockage and that my mother was at risk for a myocardial infarction. Soon, my mother was in a cardiologist’s office. The cardiologist asked a lot of questions about her medical history. He recommended angiography to verify the blockage and to see how extensive it was. He also suggested a stent at the same time to allow adequate blood flow to the heart. My mother and I asked a lot of questions about the risks. The cardiologist explained that the most significant risk was the formation of scar tissue that could narrow the artery and block blood flow again. My mother would need to receive long-term blood thinning medications such as warfarin to prevent blood clots. There were other rare but real risks, such as stroke, bleeding, and coronary artery damage. Finally, my mother asked, “Do I need a stent?” I knew my mother—she was weighing her options. The cardi-
Published Online: January 13, 2014. doi:10.1001/jamainternmed.2013.13479.
ologist could not tell for sure without angiography to see how serious the blockage was. My mother said it would be hard for her to make a decision when she is on the table during the middle of the procedure. Detecting my mother’s hesitation, the cardiologist suggested that she sign an informed consent before the procedure to authorize a stent and assured her that it would reduce the risk of a heart attack. I could sense that my mother was becoming increasingly uncomfortable about consenting to a stent when she was still unsure. I suggested that we learn more before she made a decision, so she asked about treatment options. After the physician discussed noninvasive options such as using a statin drug, my mother respectfully declined an angioplasty and a stent and decided to stay on the conservative side. We were thankful that the cardiologist did not pressure her. He prescribed a more effective antihypertensive medication and a statin to help lower cholesterol and triglyceride levels. She decided to modify her diet and lifestyle. At the end of the visit, he encouraged my mother to come back for an angioplasty if she changed her mind. At home I read more about angioplasty and stents. The medical literature says that the common complication of restenosis can happen in as many as 30% to 40% of cases, plus blood clots, which can in fact increase the chance of myocardial infarction.1 After more discussions about these risks, my mother reconfirmed her decision to decline placement of a stent. Nine years have passed, and my mother is doing well, living independently and enjoying life. She does not regret her decision to decline the angiogram and stent. During her annual checkup with her new cardiologist, her cholesterol and triglyceride levels were found to be under control. The physician encouraged my mother to keep up her good work by maintaining her healthy diet, regular exercise, and use of the right medications. Now, my mother is on another mission to try to eliminate the need for the statin.
1. Coronary Angioplasty and Stents. Mayo Clinic website. http://www.mayoclinic.com/health
/angioplasty/MY00352/DSECTION=risks. Accessed November 15, 2013.
Conflict of Interest Disclosures: Dr Yu is a member of the board of Washington Advocates for Patient Safety.
320
JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Georgia User on 05/29/2015
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