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Teachable Moment
July 2015

The Recommendation for Stenting in Stable Coronary Artery Disease—Ignoring the Evidence, Excluding the PatientA Teachable Moment

Author Affiliations
  • 1Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
JAMA Intern Med. 2015;175(7):1090-1091. doi:10.1001/jamainternmed.2015.1705

A 61-year-old executive recently came to me for a second opinion. He was hypertensive but otherwise in good health. He had been exercising regularly until 2 weeks earlier when he developed chest discomfort while walking briskly outside his office after lunch on a cold day. The discomfort subsided spontaneously when he stopped walking and returned to work. However, later that evening he grew concerned and went to a local emergency department the following day for evaluation. He described no additional episodes of chest pain. Results from 2 troponin tests were negative, and findings from his electrocardiogram (ECG) were normal. Although this episode of angina was his first, it did not occur at rest and did not result in myocardial injury as determined by biomarkers and ECG. The etiology was therefore most likely the progression of a stable, hemodynamically significant atherosclerotic lesion as opposed to a ruptured plaque with overlying thrombus as is seen in an acute coronary syndrome. A cardiology consultant who was an interventional cardiologist recommended that the patient undergo coronary angiography with a stent placement if a clinically significant blockage was found. While in the emergency department, the patient used his smart phone to search “treatment of coronary artery disease” and found abundant information indicating that optimal medication is the recommended initial treatment and that a stent would not prevent a heart attack or extend his life.1 When he asked the cardiology consultant if this was true, he was told “not necessarily” and advised to “do more research.” He declined the procedure and was discharged from the emergency department with instructions to follow up with his primary care physician.

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