A Heart With 67 Stents

A 56-year-old male with coronary artery disease presented with angina, nonspecific electrocardiographic changes, and elevated troponins. Coronary angiography revealed total occlusion of a stent in the circumflex artery, where another was deployed—his 67th stent. The patient had 28 catheterizations over 10 years, with stents placed in his native coronary arteries as well as in 3 bypass grafts. All stents were placed to relieve his angina, refractory to maximal medical treatment and transmyocardial laser revascularization. Stents can be a great tool to help revascularization and relieve symptoms; unfortunately, they are prone to thrombosis and restenosis. If they fail while medical management is maximized unsuccessfully, alternative tools are lacking. This case raises many questions: “How much is too much?” “Are there guidelines?” and “What else can be offered for symptom relief?” More studies are needed to evaluate impact on quality of life versus risks in this multistent population.

PMID: 21029877

Posted in Invasive Imaging and tagged , , , , , .

22 Comments

  1. What’s our real target for treatment?

    The following paper leads a hot discussion in China.
    A heart with 67 stents.
    AHA/ACC guidelines suggest western medication, PCI, CABG and many other devices for CAD. However, many patients complain those treatment didn’t alleviate their symptoms including my mother. It is lucky that her symptoms were gone after Chinese medicine which few American doctors study and call it complementary treatment.

    I am now in a program to study Chinese medicine. I seriously suggest American doctors to study some Chinese medicine which has different philosophy on human body. There is a Chinese word 一叶障目 which means if you put a leaf in front of you eyes, you can hardly see the whole world. Leaders of AHA/ACC guidelines set vessels and lipids as our target for treatment. However, all diseases and symptoms are caused by out of balance of the whole human body in Chinese medicine. All treatments in Chinese Medicine focus on the balance of the whole human body. None medication set vessels and lipids as target. But lipids levels go down after treatments and symptoms are gone.

    There is a case:
    A 48 years old male, 11 years of CAD history. Chest pain aggregated, hardly slept and hardly walked 100-200 m. Admission to Guangzhou Zhongshan hospital in 2007. Echo: EF 29%. Coronary angiography revealed total occlusion of three vessels and collateral circulation. He quitted PCI, CABG and heart transplantation or other devices for medical and financial reason. Doctors followed guidelines to treat heart failure and symptoms no better. Doctors began to try Chinese medicine with 生脉饮, a popular medication to increase Qi and improve digestive function. The patient began to eat a day later. He began to walk three days later. He went to shopping a week later. He climbed Great wall two years later. His EF is 39 % this year. Coronary angiography reveals total occlusion of three vessels and more collateral circulation.

    What’s our real target for treatment?

  2. Some comment on evidence- based medicine as following:
    Evidence- based medicine accept what we can see in daylightm and deny the existance of what we cannot see at night.

  3. Comments:

    American people are so rich. I have seen 8-9 stents for one patient at most in China, far less than 67.
    If this happend in China, the media would blame the doctors. The doctors and president of the hospital probably would be fired, and the family of the patient would then beat the doctors.

  4. I agree, and I am sure any physician would too, that 67 stents is a RIDICULOUS! With that number, I’m not sure evidence-based medicine could help predict the short or long-term consequences. However, this number is NOT even close to common in United States.

    But this brings up an old, and interesting crux…wealthy individuals regardless of location can pay fees for services, but as a physician your obligated to weigh Primum non nocere (Latin phrase that means “First, do no harm”) vs. Autonomy…

  5. Another Chinese doctor replied:

    His uncle got AMI and thrombolysis 13 years ago. Coronary angiography revealed total occlusion of RCA, LM 50% stenosis, LCX 80 % stenosis. He quit PCI and CABG. He practices Chinese Taijiquan and swims everyday. No symptoms now. Taijiquan, a kind of Chinese Kongfu

    Another uncle got CABG for 3 times and died.

  6. Another Chinese doctor replied: “These 67 stents became the bones of the heart.”
    He has never seen such high tech before.He admires the courage of American doctors.

  7. 67 stents, 28 coronary angiograms, and a crippled healthcare system.
    Posted Nov 01, 2010 by Dr. Eric Topol

    A recent case report in the Journal of the American College of Cardiology of a 56-year-old patient with 67 stents and a history of 28 coronary angiograms is symbolic of a healthcare system that is barreling out of control fueled by outrageous costs and unbridled use of procedures.

    Is this an example of appropriate standard of care? Should we be concerned that this case is indicative of a system that has lost its way?

  8. I have been wondering why western medicine developed so fast, but without better results. While fewer doctors like to study Chinese medicine which provides simple ways for patients prevention and treatment?

    Do you believe that doctors and big companies can earn more money if they do not cure the disease? The patients can recurrently come back to the hospitals and pay more money for examinations and medications and medical devices. Ninety percent of research from leading medical journals is supported by big companies from a statistic of BMJ 2010. No big companies like to hear that there are simple and cheap treatments in traditional medicine.

  9. well put by most in this discussion…. I’m not sure of the stent to bone comparison, but your Chinese wisdom is deeply needed in the U.S. If only we could manage patients, diets, and healthcare dollars like you do!

  10. DXY lead a new survey about ethnics of science. One thing is about multiple submissions. Western journals may think its not right for multiple submissions.

    This is a different for Chinese. Most Chinese journals only publish Chinese. Most western journals only publish English. Most Chinese readers do not read English. Most western readers do not read Chinese.

    Only a few Chinese journals with English abstracts are cited by Medline or other English Index. Chinese Indexices only cite Chinese papers.

    However, Chinese journals often translate English papers from western English journals to Chinese. The western English journals seldom translate Chinese paper to English, which make the American readers think the world can be a world without China and take expensive treatments without better results of western countries for granted.

    When Chinese doctors want to show their research to more readers, they have to make a choice. Those English papers by Chinese doctors on western journals won’t be read by most other Chinese doctors.

    When Chinese doctors wants both Chinese readers and English readers, they get a trouble. A Chinese doctor sent his research to a Chinese journal in Chinese, to a English journal in English. The western English journal made announcement about his multiple submissions.

    You know that Chinese cannot buy American books and American can not buy Chinese books. Thus, we have to make translation. Should we call English version and Chinese version multiple submissions?

    What should Chinese doctors do to those western journals only with ethnics for English?

    Liu, Qianqian MD
    Cardiovascular Department
    Peking University Shenzhen Hospital
    518036, P.R. China.

  11. Dear colleagues of ACC/AHA/ESC/GWCC,

    Thank you for your hard work in printing so many guidelines. However, obesity, diabetes, and cardiovascular diseases continues to grow.

    The following is an invention of Dr. Hua , Tuo (华佗(145-208)which has lasted for about 1,800 years, for prevention and treatment. He is the first doctor for application of general anesthesia for surgery in the earliest records of the world’s medical history . His invention called “five animals in play,” imitation of tiger, deer, bears, monkeys, birds and other beasts for the gymnastics and physical fitness. He traveled around China and taught people prevention at no cost, and has a high outcome.

    On the opening ceremony of ACC/AHA/ESC/GWCC , all cardiologists complain of expensive treatments. But who has done work as Dr Hua , Tuo (华佗)for prevention? Will your invention of cardiac imaging, interventional cardiology, surgery, genetic, and expensive medications be remembered 1,000 years later?

    I strongly suggest on the opening ceremony of ACC/AHA/ESC/GWCC next time, all leaders perform ” five animals in play” to show your wisdom for prevention and improve health of the people in heart.

    Thank you.

    Please see the related links. Content is in Chinese, but the video is self-explanatory:
    Dr Hua , Tuo (华佗)(145-208)
    http://baike.baidu.com/view/3240.htm

    国家推广标准五禽戏
    Video: The state promotes the standard of five animals
    http://v.youku.com/v_show/id_XMjI4ODUzMTIw.html

    视频:56式陈式太极拳教学
    Video: 56-style teaching Chen Style
    http://v.youku.com/v_show/id_XMTY3MzIzMzMyz.html

    The link below is a YouTube link:
    5 Animals in Play

  12. 苏胖子
    上周五出门诊见一10年前的老病人,当时前壁NSTEMI,行CAG示三只血管弥漫病变,多处狭窄在80-90%以上,当时建议PTCA或CABG,病人拒绝,之后服药也不规律,但这么多年自己也没任何症状,并对我们现在的治疗冷嘲热讽,我只能无语了!

    Translation:
    Fatty Su wrote:
    Last Friday, I met a patient who was admitted to our hospital for NSTEMI 10 years ago.
    CAG showed three diffused vessel disease, multiple stenosis for 80-90%. We suggested PCI or CABG. But the patient refused with irregular medication. He does not have any symptom and ridicules our treatment. I can only be silent.

  13. 提个不成熟的意见,这种病人全身小血管肯定都弥漫型病变了,67 Stents下去三支血管看上去是舒服多了,但是这种患者微血管病变应该比较严重,远端心肌组织的供血是否就因67 Stents而解决了啊?这么多Stents无疑增加了支架内血栓形成的风险。

    Translation:
    Chongyixurui wrote:
    I have a premature opinion. Such patients certainly have systemic diffuse small vessel disease. 67 Stents in three vessels appear to be more comfortable. But microvascular disease should be more severe in these patients. Could 67 Stents increase remote myocardial blood supply? So many stents will increase the risk of thrombosis.

  14. 中华影像小子: 看完之后,我感觉心情很沉重,就在今天上午刚刚给一个病人做了个冠脉CTA,发现两根搭桥血管、四个血管内支架,还有一个人工主动脉弓,老人很健谈,说很感谢X医生,下午他就要出院了,我还给他开玩笑说您的心脏里可放着一辆宝马车呢,您可要小心着点开啊!看着眼前这位慈祥的老人,我只能在心里默默地为他祝福,祝他永远健康!

    Translation:
    Chinese Imaging Boy wrote:
    I feel my heart is very heavy after reading it (I feel sad). I performed a CCTA for a patient this morning. I found two bypass grafts, four endovascular stents, an artificial aortic arch. This old man is very talkative. He thanks X doctors that he will go home in the afternoon. I made a joke that there is a BMW car in his heart. He has to be careful to drive this car! Looking at the kind old man, I silently blessed him and wished him healthy forever!

  15. Note: Link is in Chinese, Translation of Article can be Found Below:

    Who will pay for Cardiology Conferences?
    Southern China Weekend (very famous newspaper in China to tell the truth)
    By Mr. Cha, huiqun

    I was invited to an international cardiology conference with 2,000 people in a 5 star hotel, a beautiful place. They tell me there is such conference every week around the country. All cardiologists are supported by different companies. I was invited to talk about the topic of stent abuse. Many cardiologists think most patients do not need stents. But stents make money and more cardiologists refer stents to patients. I was deeply moved by the conscience of cardiologists. Then, I find that the cardiology conference was supported by stent companies. They told me they came to this cardiology conference without any relation to companies. They know that only doctors and hospitals can refer stents to patients. Then I know, all the food I had on that conference comes from money of patients.

  16. Hot Topic in China:

    Investigation of the Illegal Use of Stents
    Note: Link is in Chinese

    The experience of a Chinese man:

    -2007: PCI Nanjing first hospital.

    -March 25 2008: PCI Nanjing first hospital Partner bifurcation stent for clinical research. Stent without formal permission of SFDA. Cardiologists didn’t inform the patient of their malpractice.

    -Nov 20 2009: Emergency PCI Nanjing Gulou Hospital Acute myocardial infarction due to Y-stent off leading to thrombosis.

    -Jan 2010: CABG Beijing renmin hospital

    -June 2010: Heart transplantation Fuwai hospital.

    Nanjing, the first hospital, paid all the costs for this most expensive patient in history!

  17. 思絮星空: 媒体的作用究竟是推动体制的变好还是在搅局?每当碰到有关医疗的新闻,除了卫生部、国务院发布的医改剩下的全是医院药品暴利、医生对病人怎样怎样。。。却看不到整天埋头苦干,没有假期还得不到劳动法保障的绝大多数医护人员付出的艰辛

    Translation:
    Thinking Star:
    What is the role of the media, to improve the system spoil? All news comes from the Ministry of Health, the State Council issued the Health Care Reform, the Hospital Pharmaceutical profits, how doctors treat patient. . . They cannot see the hard work of doctors and nurses, no holidays, and without protection of labor law.

  18. Note: Links are in Chinese

    Hot movies of American cardiac imaging for new year ” Let stents fly” and ” Let CCTA fly”
    Dr. Liu , Qianqian

    Comment on ” Let stents fly” and ” Let CCTA fly”
    Chief Executive Editor Dr. Hu, Dayi, MD FACC FESC
    Chief, Heart Center
    People Hospital of Peking University
    President
    Chinese Society of Cardiology (CSC)
    President
    Chinese College of Cardiovascular Physician (CCCP)
    Email: dayi.hu@medmail.com.cn
    Web: www. gw-icc.org
    see also:
    http://www.cscnet.org.cn/news_show.jsp?id=33.html
    Translation:
    The two extreme cases actually reflect events of universal significance which should be fully concerned by doctors worldwide.

    There are too much unknowns from diagnosis to treatment in medicine which will inevitably lead some unnecessary technology in the process. Single bio-medical model inevitably leads to technology first, worship of scientism and the tendency of over control by biotechnology on human health and disease. Or even single expectation on biotechnology development, huge investment on biotechnology research and the expected return interact huge thrust. Overuse of medical examination and treatment are widespread around the world. Medical operations in the system with comparisons of gross income, as well as quantify the distribution system, with obvious benefits and lure for guidance, and technical supremacy, technology worship lead to money talks.

    Why is the proportion of coronary angiography to achieve even more than 50% normal results in some hospitals ? Why do drug-eluting stent implantations account for more than 96% of total stents in China, far exceeding the proportion of any country in the world? Why do a large number of patients with left main and multi-vessel disease receive multiple stents rather than CABG ? Why is the ratio of PCI and CABG up to 11:1 ? Do patients of stable angina need coronary angiography and stent treatment? If not, how many patients received this treatment?

    To be continued.

  19. Drug-eluting stents have been extensively studied, and are generally superior to bare-metal stents in regards to future major adverse cardiac events such as death, myocardial infarction, or the need for a repeat revascularization procedure.

    I don’t think a lawyer’s blog has much creditable information.

  20. 现代科学是物理学,西医把现代科学用于医学,所以只能称为物理医学,但人体不是物体,而是生命体,生命体遵循的是生命学规律,而不是物理学规律,西医完全用物理学规律来揭示生命学规律,还顽固地说自己是唯一的科学,真是太过固执。只有中医是用生命学规律来揭示人的生命规律,反而被西医认为是不科学,真是科学的悲哀。

    西医是把人体当作物体对待的,物是不能自动的,必须靠外力来推动,推之则动,不推动则不动,所以西医治疗什么病都是不停地推动,只要停止推动,它就自动停止。高血压必须终生给降压药降压,停药则反复,失眠必须长期用镇静药镇静,所有病都只能控制,而不能根除,明明这是西医的方法论带来的不能克服的致命伤,但西医还顽固地说这是唯一的科学,说病就不能根除,就只能长期控制。中医是把人体当作生命体看待的,生命体可以自动,不需要外力来推动,所以中医治疗各种疾病都不是推动人体,改变疾病,而都是改变人体,让人体自动,只要人体自己能动了,就不需要医生再来推动,所以中医治什么病都是根除,只要病治好了,就不需要再用药。明明这才是生命科学意义的科学医学,反倒因为不符合物理学的科学标准而被诬为不科学,真是科学的悲哀。

    Note: Translation

    Modern science is physics for modern Western medicine, it can be called physical medicine, but the body is not an object, but a being. Life, and the body follow rules, not laws of physics, complete with Western medicine laws of physics to reveal regular patterns of life, but also stubbornly said that he is the only science, is really too stubborn. Chinese medicine is only the regular patterns of life to reveal the laws of human life, but was Western medicine as unscientific.

    Western medicine is to treat the body as an object, the object is not automatic, must rely on external forces to push, so the Western treatment of any disease are continually promoted, as long as they stop pushing. But Western medicine is also stubborn to say this is the only science, that disease can not be eradicated, it can only be long-term control. Chinese medicine is to treat the body as a living body, the life of the body automatically, without external force to push. So, the Chinese medicine treatment of various diseases is not to promote the human body, changes in disease, and are changing the human body, allowing the body automatically, as long as his body is dynamic , and doctors do not need to push again, so in the treatment of any disease is eradicated, as long as the cure, and you do not need further medication. Obviously this is the meaning of life science scientific medicine, because they do not meet the standards of physical science has been accused of unscientific.

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