An audit of angioplasty cases performed under the state’s free insurance scheme has shown that multiple stents could be associated with a higher risk of death.
MUMBAI: An audit of angioplasty cases performed under the state’s free insurance scheme has shown that multiple stents could be associated with a higher risk of death.
The audit, published in the international medical journal PLOS One, found that 203, or 4.5% of the 4,595 patients under the Rajiv Gandhi Arogya Yojana who were studied, died within a year of angioplasty. Most deaths had occurred in patients with multiple stents or longer stented segments of arteries. The study said total stented length greater than 31.5 mm was associated with mortality.
It is of grave concern that similar studies in the West only had 1% mortality, said the study’s chief author Dr Bhanu Duggal, a cardiologist from the state-run JJ Hospital in Byculla, explaining the need for such clinical audits to strengthen the healthcare system.
“While deaths occurred in patients in the 35-75 age group, most were elderly,” it said. Many of them were unemployed. Also, patients who received bare-metal stents had a higher incidence of re-hospitalisation or repeat procedure than those who received the more sophisticated drug-eluting stents.
The study was aimed at providing some evidence-based medicine at a time when overmedication and over-stenting are emerging as issues plaguing the healthcare system, said IAS officer Meeta Rajeevlochan, who commissioned the study in 2012 while heading the health and family welfare department. She said judicious use of stents could improve survival rates and decrease healthcare costs.
Importantly, the study questions the present cardiological practices in India. “At present, most of us do a visual assessment of the blockage before deciding to stent it,” said Dr Duggal. In the West and Indian metros, stress tests, nuclear scans or sophisticated techniques such as fractional flow reserve (FFR) are used to establish if a blockage is indeed so huge that it prevents complete blood flow.
“Not every blockage that is over 70% needs to be stented,” said Dr Duggal. Only those that cause pain or other physiological symptoms should be stented. The present practice across Indian hospitals is to announce that a patient has three-vessel blockage that would require, say, three or more stents. “Cardiologists need to first locate the problem blockages and only tackle those,” said the doctor.
Not all doctors agree with the study findings. A senior cardiologist said if people need multiple stents and longer stenting length, it means they are sicker and have extensive heart disease. “There is a higher likelihood of these patients dying,” he said.
Indians are prone to heart attacks a decade earlier than Caucasians. “Medical textbooks say heart diseases can be classified into one-, two- or three-vessel diseases and each incidence is equal to a third. But in India there is a higher possibility of finding people with two or three-vessel disease, meaning they will require more stents,” said another doctor.
The doctor pointed out that the state government study included small centres, where the possibility of using bare metal stents is higher, which increased the risk of death.
New research in the West is now focused on longer stents, he added. “The longest stent we have at present is 48mm but there is talk of a 60mm stent being introduced in the near future,” he said.
Doctors said the focus should be on early detection of the disease so that fewer stents are required.