Excessive and unnecessary use of stents is becoming increasingly common today. So look before you leap into that stenting procedure advised by a cardiologist, says Hemchhaya De
Dipak Sen has decided that he will fight to the finish. The 72-year-old, who lives in south Calcutta, lost his wife, Dipti, a couple of years ago. She was admitted to a leading multi-speciality hospital in the city after she experienced acute chest pain. She was advised to opt for angioplasty and stent procedure by a senior interventional cardiologist associated with the hospital.
Five stents (tiny metallic wire meshes or scaffolding devices that are inserted in the heart to keep clogged arteries open in order to facilitate blood flow) were used. But soon after the procedure, Dipti’s condition deteriorated and she died within a few days. “Later we found that the doctor put stents even in areas where they were not needed,” says Sen. “My wife had diabetes and we believe that the large quantity of dye injected to put the five stents might have affected her kidneys. How could the doctor overlook her diabetic condition?”
“Each imported stent cost us around Rs 1,20,000 and the total hospital bill ran up to Rs 16 lakh,” says Sen. He complained to the West Bengal Medical Council, but to no avail. So he moved the state consumer disputes redressal commission, seeking stringent action against the doctor and a compensation of Rs 50,00,000. The case is now pending in the consumer court.
If you are unfortunate enough to have had an angina episode, and are diagnosed with arterial blockage in your heart, you may be advised a stenting procedure. But before you make your way to the gurney, you have to be thoroughly sure that you are not being taken for a ride by the cardiologist and that you do indeed require the procedure.
Incidents of excessive and unnecessary use of stents are becoming quite common today. Recently, the Medical Council of India reportedly indicted a senior doctor at Safdarjung Hospital in Delhi for unnecessary use of stents on a patient.
Going by the book, stents are advised when patients have more than 70 per cent blockage in their coronary arteries. As Dr Upendra Kaul, executive director and dean of cardiology, Fortis Hospitals, New Delhi, explains, “Angioplasty is recommended only where the arterial blockage is more than 70 per cent. Non-critical lesions that are less than 50 per cent need not be treated by angioplasty or stenting. These blocks may actually go away with aggressive medical treatment.”
Despite that, stents are being inserted even in cases where there are 30-50 per cent blockages. “Doctors in Calcutta and elsewhere are recommending stents even if there are 40 per cent blockages,” says Malay Ganguli, secretary, People for Better Treatment, a Calcutta-based civil society group that fights medical malpractices.
Of course, the malpractice is not confined to India. The New York Times reported recently how a Baltimore cardiologist inserted 30 stents in patients on a single day and was amply “rewarded” by a premier stent manufacturer for this.
Although only a handful of such cases grab media headlines, it’s widely acknowledged even within medical circles that doctors indulge in excessive use of coronary stents because enticing kickbacks from manufacturers and distributors are hard to ignore. “It’s true. It’s an industry-driven practice and the incentives are lucrative,” says Dr K.M. Mandana, director, cardiac surgery, AMRI Hospitals, Salt Lake, Calcutta.
Hospitals too stand to gain if a patient is given a stent too many. “Doctors are needed to fill their quota of angioplasties or stents or pacemakers as dictated by the hospitals they work with,” says Ganguli.
Experts argue that tests have shown that bypass surgery is preferable to stenting in some cases. “If blocks are seen in all three coronary vessels, they are usually considered for bypass surgery as the stents are prone to get blocked much earlier than bypass grafts,” elaborates Dr Tapas Ray Chaudhury, director, cardiac surgery, Woodlands Hospital, Calcutta.
Dr Ray Chaudhury feels that in India cardiologists do tend to use stents in an arbitrary fashion. However, Dr B.K. Goyal, director, interventional cardiology, Bombay Hospital, Mumbai, dismisses the allegation. “No cardiologist with proper credentials will insert stents unnecessarily,” he says.
Patients and their families also have to watch out that they are not overcharged for stents. A 54-year-old man in Pune has reportedly lodged a complaint with the Drug Controller of India and other Indian regulatory bodies against a hospital which handed him an “inflated” bill for stents.
At present, two kinds of stents are available in the market — bare metal stents (BMS), which are mechanical devices that came into the market in the late 1980s, and the more recent drug eluting stents (DES), which are coated with a drug.
As per unofficial estimates, around 2,00,000 stents are used in India a year. “The DES accounts for 60 per cent of the market while BMS accounts for 40 per cent,” says a senior manager (who doesn’t wish to be named) with Sahajanand, Gujarat, one of the leading Indian stent manufacturers. International giants like Johnson & Johnson and Abbott also occupy a fair share of the Indian market. Indian DES are priced between Rs 75,000 and Rs 90,000 while imported ones can go up to about Rs 1,25,000.
It is alleged that hospitals buy stents in bulk at reduced prices, and then they jack up the prices while selling them to patients. “If they have paid Rs 45,000 per stent, they will charge a patient Rs 75,000-Rs 90,000 for the same stent. Almost all major hospitals in the city are guilty of it,” says a stent supplier in Calcutta on condition of anonymity. “Plus each distributor sends sales representatives to doctors in private as well as public hospitals to encourage them to sell more and more stents. Even cath lab (where angioplasty and stenting procedures are carried out) technicians get a cut!”
What’s more, there’s no minimum retail price for imported stents, he adds.
Indeed, when it comes to stents, there are allegations and counter-allegations galore. Some doctors say although DES begins to function like a BMS after three months, patients are encouraged to opt for them because they are more expensive.
Others say one must be aware of vested interests. Stenting, which, needless to say, is a big business in India now, is done mostly by interventional cardiologists. And they claim that it is only cardiac surgeons who always criticise the procedure as they are deprived of “cuts”.
In the midst of all this, consumers can’t be too careful. If your cardiologist advises stents, remember to go for multiple tests to assess the degree of blockage, weigh the pros and cons of stenting and then, and only then, make an informed decision.
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