But eventually, the dust settled. White, Gacioch and Boden all agree that what emerged from the fray is a more medically conservative field of interventional cardiologists.

At the University of Buffalo, Boden says he there has been a sustained 15 to 20 percent decline in the volume of cardiac catheterization requests and associated stents and angioplasties in the past few years.

In New Orleans, there is a similar downward trend. “Stents are absolutely being used less,” says White, a decline that has held steady for the past few years.

Boden’s and White’s observations might seem odd given the data, however. Stents remain a popular therapy choice. Although there was an initial drop in the rate of stent placements—nearly 13 percent nationwide in the months after Courage’s publication, according to Millennium Research Group—the number of stents has remained high.

The AHA, which keeps a tally of all heart procedures in the United States, mistakenly double-counted procedures until recently. Even with the figures adjusted for this error, the number of stents has consistently remained more than 500,000 per year.

White offers an explanation for this discrepancy in numbers: baby boomers. He points out that as the next generation of patients hits their 50s and beyond, the number of heart-associated diagnoses will increase as well. “We see more patients every year,” says White. “We’re seeing more people that need to be treated, but the percentage of stents [being used] is growing smaller.”

Stents continues to outpace other medical devices in the market as well, accounting for nearly $5 billion worldwide and making it one of the most popular medical devices globally. Joseph McGrath, a spokesman for Medtronic Inc., a Minneapolis-based stent manufacturer, predicts that the market will remain healthy.

“Stents are an example of an innovation that has absolutely changed the way coronary artery disease is treated,” says McGrath. “And it will continue to play a role in treatment.”

But McGrath is quick to point out that Medtronic Inc. only produces the stents. “We don’t practice medicine,” says McGrath. “Physicians have the latitude based on their discretion to use the device in a way that’s not on the label.”

According to White, a physician is almost entirely driven by evidence. “When there is data, we use evidence-based medicine,” he says. “But when there’s no evidence, that’s where the art of medicine comes in.”

Boden also points to larger, more systemic problems that might be driving aggressive use of medical procedures like stents. “In the United States, we reimburse physicians and hospitals on a fee-for-service basis,” Boden says. He points out that when incentives are in place, practices will become more common, even if they’re not necessarily in the best interest of the patient.

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