Consultancy Corner: To stent or not to stent

In fact, a quarter of all mortality today is attributable to CVDs. Although treatments such as cardiac stenting, bypass surgery and other advances in cardiac treatment have shown positive impact on quality of life for many people, there needs to be a sharp focus on accurate diagnosis.   

The good news is that we are witnessing continued advancements in improving the treatment approach and management of coronary artery disease (CAD). Today, there are many breakthrough tools that are helping cardiologists make precise treatment decisions. A hi-tech micro sensor technology called Fractional Flow Reserve (FFR) enables the right treatment strategy, by providing in-depth functional analysis of blockages in the heart. This invasive tool helps by measuring the blood flow inside the artery and enables us to take more prudent decisions on deciding treatment strategies.

In clinical practice, the decision to proceed with stenting/ surgery becomes particularly challenging when it comes to intermediate blockages of ~60 per cent involving multiple vessels. In many of these cases, patients are often under-treated based on the angiographic evidence, or sometimes they end up being over-treated by undergoing unnecessary stenting or surgery. FFR is an excellent modality to accurately assess the need for stenting of a narrowing blood vessel in the heart. With the advent of this technology, cardiologists have been able to confidently identify the culprit blockage and stent only those blockages which really require an intervention, thus improving patient outcomes and 

avoiding unnecessary stenting. FFR helps by measuring the pressure of the blood flow in the distal part of the blocked artery and provides an assessment of the severity of the blockage impacting the blood supply to the heart. Thus, it provides the cardiologist with a quantitative technique for confidently evaluating the extent of coronary artery disease and take appropriate decisions.

Research now proves that an insignificant FFR value shows the blockage does not need angioplasty, and the patient can be safely treated with optimal medical therapy. 

I recall treating a 70-year-old female patient five years ago, wherein she had blockages in all three major heart vessels and was suggested surgery by various doctors. An FFR measurement on all the blocked vessels was done, which showed a value of more than 0.8 in all three vessels. This value showcased the fact that she did not require a stent/surgery and could be treated by medication alone. She is doing absolutely fine now. Like her, there are many such patients who can avoid unnecessary treatment procedures. 

European society for Cardiology (ESC) guidelines has classified FFR as Class 1 level of evidence A, which is the highest level of endorsement that a medical technology can receive. The efficacy of FFR is also backed by significant scientific evidence. We published our experience with FFR through FIND study , which compares the treatment strategy with and without FFR measurement in 59 Indian patients and 81 blocked blood vessels. The study showed reduced stent usage by 42 per cent and reduced number of surgeries by 50 per cent when FFR is used to evaluate the blockage. This clearly proves the efficacy of this hi-tech technique to decide the best treatment with precision.