Do I Actually Need a Stent?

If you had a heart attack, a stent saves your life. If you have stable chest pain on exertion (the kind that gets better when you stop walking) a stent adds zero years to your life and prevents zero heart attacks versus medication. The COURAGE trial (2007) and the 5,179-patient ISCHEMIA trial (2020) both showed no reduction in death or heart attack; the sham-controlled ORBITA trial (2017) showed it doesn't even improve exercise time beyond placebo. (It can still ease angina symptoms; that benefit is real and is the honest reason to consider one.) American cardiologists still place roughly 400,000 elective stents a year. The patient usually has no idea the evidence looks like this.

The word "stent" describes a metal scaffold that holds a coronary artery open. Placed during an acute heart attack, when a plaque has ruptured and a clot is cutting off blood, it restores flow and stops the death of heart muscle. That is a life-saving procedure, and if you're ever offered it in that setting, take it.

Placed electively, for stable angina, it is a different procedure. The artery is narrowed but flow is still adequate. The stent opens it more. You feel better for a while because you believed it would work (placebo is powerful; ORBITA demonstrated this with a sham-surgery arm). Your mortality risk is unchanged. Your chance of a future heart attack is unchanged.

Fractional flow reserve is a wire threaded through the artery that measures actual pressure drop across the narrowing. An FFR above 0.80 means the narrowing is physiologically insignificant: meds only. Below 0.75, the narrowing matters. Between 0.75 and 0.80 is the gray zone.

If you're being offered a stent without an FFR measurement, ask why. The answer is usually that the cath lab is busy and FFR adds twenty minutes. That's not a reason to cut you.