ROBERT SIEGEL, host:
Dr. Stuart Seides is associate director of cardiology at the Washington Hospital Center, and a frequent guest here when heart disease is in the news. Welcome back to the program.
Dr. STUART SEIDES (Associate Director of Cardiology, Washington Hospital Center): Thank you. It's a pleasure to be here.
SIEGEL: And first, how much is this finding that Dick Knox has reported on likely to alter the decisions of you or your fellow cardiologists about implanting stents?
Dr. SEIDES: I think it depends where you start. I think this study creates an appropriate middle ground for consideration of both medical therapy and stenting, and patients who have chronic coronary disease and angina. So whether it changes your approach depends on where you start. If you were a cardiologist who felt that everybody who have angina needed a stent, then this should move you more toward considering medical therapy.
I think many of us have been somewhat thoughtful over the years. And for some of us, this simply validates an approach to individualized treatment to each patient.
SIEGEL: But it sounds as though what you're saying is some cardiologists will be recalibrating their approaches to these various therapy alternatives.
Dr. SEIDES: Indeed, they should.
SIEGEL: If a patient with a stent came to you and said I just heard this story on NPR. The stent doesn't improve my chances of avoiding a heart attack or sudden death. Should we take it out? What would you say to him?
Dr. SEIDES: Well, as a practical matter, stents really cannot be removed once they're implanted. But this study did not imply that there was any harm to stenting. It simply said that stenting in these patients with chronic coronary disease did not improve the hard outcomes of death or myocardial infarction or heart attack. So I think those who have stents who are doing well should be happy and keep their stents just where they are.
SIEGEL: In the whole range of treatments or preventives for heart disease - from bypass surgery or angioplasty to stents with drugs or without taking drugs - is the field changing at all over the years now? Do we see some favorites or some that are losing favor with cardiologists, especially?
Dr. SEIDES: Well, one of the difficulties in this field is that there are a lot of moving targets. The whole field has a lot of moving parts, because technology continues to evolve as we attempt to make treatment decisions in real time. And even the technology of stents themselves are being refined: new mechanics, new drugs that are being added to them, and some stents that are implanted and even disappear after a period of time, or absorbable.
SIEGEL: But given the thousands of people who are subjects in the experiments that Dick Knox reported on - the paper that was released in New Orleans, I gather - we know how common this has been. Why so long to come up with a finding about the efficacy of the stent as opposed to medication without the stent?
Dr. SEIDES: Well, I think part of it relates to our evolution of understanding about this disease. I think that initially, we were very enthused about opening blockages and getting rid of the blockages, feeling that was going to protect patients against heart attack. It turns out that that may not, particularly in stable patients. And I think that's an important...
Dr. SEIDES: ...effect to emphasize, that patients who are unstable or have had a small heart attack were not included in this group of patients.
SIEGEL: We're talking about about a description of the plaque in the arteries of the patient, right?
Dr. SEIDES: It's the clinical presentation which, by implication, tells us things about the plaque in the artery that are different in acute patients versus chronic patients.
SIEGEL: Well, Dr. Seides, thank you very much.
Dr. SEIDES: My pleasure.
SIEGEL: Once again, Dr. Stuart Seides, who is associate director of cardiology at the Washington Hospital Center.
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