The first 30 days after undergoing the stent procedure is called the vulnerable period. If the patients don’t take their medication, the risk of stent clotting is extremely high, said Dr Sripal Bangalore, Director of Interventional Cardiology at Bellevue Hospital and Professor of Medicine at NY School of Medicine.
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In the dynamic landscape of cardiovascular care, advancements in stent technology have been pivotal in improving patient outcomes and reducing risks associated with coronary interventions. Dr Sripal Bangalore, Director of Interventional Cardiology at Bellevue Hospital and Professor of Medicine at NY School of Medicine in an exclusive interaction with ETHealthworld’s Rashmi Mabiyan Kaur elucidates the evolution of stent technology, the significance of medication adherence post-procedure, and the challenges and prospects of cardiovascular care in India. Edited excerpts:
Q. What specific advancements have contributed to reducing the risk of re-blockage and stent clotting in patients undergoing coronary interventions?
The research continues to make the stents thinner as it has shown improved benefit to the patients. What has been shown from all of the research is once you make the stents thinner, it has an impact on the outcomes of the patients. So the risk of re-blockage is significantly less and the risk of stent clotting is also reduced. So just making the stents thinner has been one of the biggest progress in stents technology.
Just going from a biomaterial perspective, we used to have the stainless steel stents. If you make the stainless steel stents thinner, it loses it radial force. It doesn’t have the strength. This led to the development of the cobalt-chromium, platinum-chromium materials, where you can make it thin and at the same time strong enough to make sure that the vessel is kept open. Then there have been other changes in the polymer that surrounds the stent, all geared towards making sure that the risk of events from a stent is considerably lower.
There have been several clinical trials in which it’s clearly shown that all of these improvements are making an impact on our patient-related outcomes. The risk of heart attack, and re-narrowing is less and stent clotting is also significantly lower.
Q. Given the variations in stent availability and regulatory standards between the US and India, how do you assess the quality and efficacy of stents in the Indian market?
The USFDA has very strict regulations. If you want to get a stent there, it has to pass through the rigours of clinical trials, and that’s the only reason it will be approved. This is a reason why we only have a handful of stents approved in the US, so we don’t have the same number of stents available in India. According to me, when you flood a market with many different stents, and specifically if they have not gone through the rigours of clinical trials that can be a concern but you have to actually prove that they are making a difference in patients related outcomes.The challenge here in India is you not only have stents that have been tested before, including many of the avid stents but there are many Indian stents also where they haven’t gone through the rigours of clinical trials. Although on paper it looks great, I need to see evidence to make sure they are at least on par with the other stents.
Q. Could you elaborate on the significance of medication adherence post-stent placement, and how it impacts the risk of stent clotting and patient outcomes?
The first 30 days after undergoing the stent procedure is called the vulnerable period. If the patients don’t take their medications
within the first 30 days, the risk of stent clotting is extremely high. It is at least 5 to 10 per cent and the reason why this is important is because if there is clotting, it will lead to heart attack and some patients may die even before reaching the hospital. So medication compliance is absolutely important as there is a significant increase in deaths and heart attacks.
Nowadays, the stents are so good that if they take their medication for one year, the risk of stent clotting is less than one per cent. Unlike 10-15 years ago, now stents have improved to the extent that you don’t need to take medications for 1 year or 2, but make sure to take them at least for three to six months.
Q. How do you envision the application of Artificial Intelligence (AI) in enhancing PCI techniques and stent procedures, particularly in addressing challenges posed by treating sicker patients with multiple comorbidities?
We made significant changes in our stents, and the outcomes are better. Now we treat more and more sicker patients. Patients are getting older, they have more comorbidities because they’re living longer. So the PCI techniques have become challenging. So what I would like to see is more improvement in stent technology, AI algorithms for intravascular imaging and AI involvement to plan my procedures better.
Q. What factors, including genetic predispositions and lifestyle changes, do you believe contribute to the increasing incidence of heart attacks among young individuals in India, and what ongoing research is shedding light on this phenomenon?
There have been several studies trying to figure out why we have premature coronary disease among South Asians, specifically in India. Partly could be genetic, if you look at their lipid profile in India, they don’t tend to have the usual risk factors of bad cholesterol being too high.
May be, there are other kinds of lipid profiles that are currently being investigated. Some therapies have been tested in clinical trials. The comorbidities clearly are increasing dramatically. We are seeing that there is a significant increase in obesity, and the number of patients with diabetes.
Q. Considering the unique challenges posed by premature coronary disease in India, what actionable steps do you recommend for raising awareness about heart disease symptoms, ensuring timely medical intervention, and promoting heart-healthy lifestyles among the population, especially the younger demographic?
In India, we hear about cases like very young patients in their twenties, or thirties, coming with a heart attack which is very rare in the US. We don’t see it in the majority of the world. The key is to make sure that there is greater awareness of the symptoms of heart disease and to make sure that people are aware of the consequences. If someone has discomfort or chest pain, it may be heart disease or a heart attack, but mostly they don’t realize.
A blocked artery can affect their entire lifespan. If the muscle is infarcted, there is no coming back. So the heart will be weaker and they will suffer the consequences of either dying early or having heart failure. So, there needs to be more education and awareness on the symptoms of heart attacks as India is witnessing a lot of young patients with heart attacks.
