Tonight, I am going to stick up for my interventional cardiology friends. These are the good folks who respond immediately (and I mean immediately) when you have a heart attack. They open clogged arteries. Like Jack Nicholson said, “you want these guys on the wall.â€
Why do I feel the need to take up for the apex-predators of Internal Medicine?
Because bio-statisticians and academics are trying to make treating heart disease seem way easier than it really is.
Take this most recent meta-analysis (Archives of Internal Medicine) of stents versus medical therapy in patients with “stable†coronary disease. The researchers pooled multiple previous trials where stents and meds were compared and found no difference in outcomes. (Detailed summaries are available on TheHeart.org and Cardiobrief.) It’s not intuitive to think that stenting open an artery (sometimes from 90% to 0%) does not reduce the chance of death, future heart attack, or unplanned heart surgery. But this data looks very real.
Adding to the piling-on effect was an invited editorial from Dr William Boden, the lead author of the Courage Trial, which just so happens to be the ‘landmark’ study of meds versus stents. In 2007, in the NEJM, Courage investigators concluded “PCI [stents] did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.” Asking Dr Boden how he feels about this meta-analysis is like asking me if the double Ironman is dumb. Of course, Dr Boden thinks treating blockages with stents is overrated.
Let’s insert a real world view:
The reality here is that treating major blockages in the heart (as if there were such things as minor blockages) with only medicines constitutes very aggressive and risky behavior.
Consider these common scenarios:
A patient presents to the emergency room with atypical, fleeting and clearly non-heart-related chest pain. Or perhaps a marathoner wants a stress test; or a diabetic patient needs pre-op clearance.
Unless a patient’s risk of heart disease approaches zero, a rarity, they get referred for further testing, which means looking for blockages. Remember, there is no room for being wrong–none. Perfection. Never be wrong.
So, the patient comes for a stress test. “Ma’am, we are doing this test to look for blockages.â€
Alas, the stress ECG looks a little funny. Suspicions arise. Never comes up again; never be wrong.
“Ma’am, your stress test is positive…I think you should have a cath…This is a test where we look for blockages in the heart’s arteries.â€
Heart doctors usually recommend looking for blockages after positive stress tests because untreated major blockages may lead to bad outcomes, like death.
The consternation starts when the cath shows an 80% blockage. Before the meta-analysis and trials named Courage, a heart doctor would squish and stent the blockage and render the artery 100% clear, or 0% blocked. That part of the heart gets more blood; the patient feels fixed; the doctor declares victory.
Both the general public and the majority of the medical world view this scenario as ‘normal.’ The story is told in doctors’ lounges, on golf courses and even on bike rides. “My heart doctor fixed my blockage.”
What the public doesn’t know is that 80% blockages aren’t often the ones that will cause the future heart attack. Rather, heart attacks come from the 10% blockage that gets nary a mention, or is called a minor blockage.
Back to medical therapy: the reason why lowering cholesterol with statins, treating high blood pressure, using adrenaline (beta)-blockers and instituting lifestyle changes can produce equal outcomes to stents is that such measures target the disease of atherosclerosis at its root, whereas stents just fix the end-result.
Ah…But here is where real life makes it tough to implement such an academic strategy. It’s very hard to walk away from an 80% blockage. What do you tell your patient if she wants to run, or play tennis? What about the next time someone cuts her off in traffic and adrenaline levels surge? What if it was your left anterior descending artery—you know, the “widow-maker†artery? Finally, imagine explaining to the primary care doctor that it was a good idea to leave the artery 80% blocked? I’m not sure about how things roll in Boston and Hanover, but this would be a tough sell in Kentucky.
My eye-surgeon friend said it well when she noted how stressful it would be to work on the heart. Why? I asked. “Because people have two eyes but only one heart.â€
Conclusion:
I’m putting my money down that aggressive targeting of atherosclerosis, not just with pills, but strict attention to diet, exercise and behavior modification, could indeed equal stenting. But there are a lot of unknowns with this strategy:
Will the US ever accept a healthcare system that allows doctors not to exclude everything possible? Maybe then we could stop doing so many stress tests and caths?
Will heart patients ever be expected to help themselves? Could a recommendation to stop smoking, eat less, exercise more and take a few basic medications be considered adequate medical treatment for a blockage? Or will such advice continue to be labeled as mean, unfeeling and not doing everything?
And here’s a biggie question:
How many of the 23 authors of Courage would accept medical therapy of their 80% blockage once they saw it?
JMM
15 replies on “Only one heart: Treatment of Coronary Artery Disease in the Real World”
Hello John – interesting dilemma. As a heart attack survivor and “stentee” (fully occluded LAD) I knew nothing of stents, cath labs or heart disease until I was introduced to them under emergency conditions in ’08. But what I’ve learned since then has introduced me to the possibility that when you are an interventional cardiologist armed with a hammer, everything out there looks exactly like a nail. Docs believe it. Patients believe it. Insurers believe it. Even the patients of the stent-happy Dr. Mark Midei of Maryland, when notified that their 90% blockages turned out to be only a 10% blockages upon review, were reported to insist that Dr. Midei had “saved my life”.
You once wrote here (brilliantly, I might add): “We urge patients to eat less, exercise more, and not to smoke. But when they don’t do these things, we still squish their blockages, burn their rogue electrical circuits, and implant lifesaving devices in their hearts.”
And as long as cardiologists keep doing these procedures without simultaneously writing a prescription for lifestyle improvements, we’ll still be talking about this a decade from now.
3 years ago I had SOB on exertion. Lasted 4:30 on the stress test. Cath showed 70% blockage in LM, at the bifurcation, and left circumflex. CABG x3.
Did not have a full workup after that. But increased PVC’s, needing to monitor MVR, and a slight tingling in my arm after a series of hills on my bike I had a holter and stress/echo 2 weeks ago.
All OK except echo showed on very small area of reduced wall motion.
Dr said that I could wait and see or do an cath. I decided to wait and see. And part of that reasoning is what would change in my treatment if I had the cath.
And with this report what would be gained except possibly a stent and then the added treatments that go with that.
Now I do have a number of question about the details of this finding, but I will wait until the next 6 month followup to ask them. And I doubt that it will change my mind. But I like being a fulling informed as I can be.
Now if it included limiting angina or SOB my decision would be very different, so matter what this report said.
In 2005, I experienced chest pain while climbing a steep hill on my bike. Turns out I had a 100% blockage in the RCA. A stent was inserted, but some damage had already been done. So, ate right, lost weight, took meds, and exercized regularly, never smoked. (Maybe I overdid it some. I was riding century rides almost monthy.) Total cholesterol was under 100. HDL and LDL within normal range. In 2009, again while cycling, had some chest pain during hard efforts. Neuclear stress test showed 90% blockage in LAD, Another stent. My lesson learned was that life style changes can’t fix everything either. Sometimes, one is just dealt a hand from a stacked deck.
The message I get from your “common scenarios” is never, ever submit to a stress test for which there is no indication, because it could lead to a needless cath and then some needless stents and then maybe a needless stroke or needless cognitive impairment or a needless Plavix habit. And if 80% blockages are not the ones that cause heart attacks, and exercise reduces death rates in heart patients with actual symptomatic disease, why would you even consider making your hypothetical “patient” fear her tennis game? Please understand, I do recognize the stresses and real risks that doctors face. These studies have proven that stenting for such a person does not save lives over OMM, period, and yet if this woman is in the tiny fraction of such individuals who actually have serious heart attacks, you could have some plaintiff’s attorney in your face: Why didn’t you Do Everything Possible? You are not going to be sued if she gets stented, even if she suffers lasting harm from it. When a doctor is not just in it for the money, that’s terribly unfair, and I am sympathetic.
But my husband has atrial flutter (which is why I read your blog) and temporarily suffered from CHF, and during his first serious exposure to cardiology he was subjected to life-altering malpractice involving at minimum three physicians (and no, we have not sued). Since then, nothing is done to him unless I go through all relevant clinical trials first and okay it. Over and over, there have been attempts to shove him towards the most aggressive possible treatments and procedures, sometimes for conditions he does not even have. While money is no doubt a factor, it is not the only factor. Drugs with very poor risk-benefit ratios have been pushed by doctors who will not profit from writing those prescriptions. During his first hospitalization (which caused the next two, which he says will be his last), two salaried staff electrophysiologists treated us like dogs, literally shouting and sneering insults, because while he was deceived into accepting a pacemaker he did not need, he retained enough backbone to refuse an ICD for which, as we later confirmed, he also had no indication. Had he submitted, as things turned out, the consequences would likely have been devastating. One of those two docs does apparently profit from ICD-promoting research; maybe the other was sued last year and is now trying to coercively four-plus everyone out of fear. Maybe most, or even all, of these doctors have litigation-related PTSD and see every conservatively inclined patient as a potential plaintiff. If so, I’m very sorry about that, but I will match our stress and fear and rage against theirs any time. Further, for every one doctor who suffers there are hundreds of patients whom he causes to suffer in turn, most of whom will never understand when they have been needlessly damaged. The above article seems to say: “Don’t look to me to educate patients when a procedure has no benefit; I’m too busy covering my own rump.” And you’re notably more rational than an average cardiologist. How is a patient then supposed to know whether they really need what their doctor claims they need?
John,
There are several important issues raised by the comments to your article. First, if you have an acute coronary syndrome (unstable angina, NSTEMI or STEMI) then a PCI is clearly superior to medical therapy. If you are having an MI get to a PCI center, not a ready care or hospital that doesn’t do PCI. Second, for stable coronary disease PCI has never been proven to save lives versus medical therapy. Coronary disease is usually a widespread problem throughout the coronary circulation and not in an isolated location. A stent places a band-aid on the problem. The cause of the coronary disease has to be treated or more problems will occur. When dealing with stable coronary disease it is important to assess the amount of myocardium at risk. This can be done with stress testing or also in the cath lab with FFR. Stenting little branches often does little in the long run. Treat that medically and if it fails to alleviate symptoms then do a PCI. Thirdly, it always amazes me when very bright people research which coffee maker to buy more than which cardiologist they see. A good unbiased resource is a nurse or sometimes a medical sales person. Careful with the sales people they sometimes have conflicts of interest.
Thanks Dr D. I appreciate this highly instructive comment. You are always good, but this one is special indeed.
See folks, this is why social media is so helpful. The words are real, unfiltered and meant to help. Why does Dr D bother to muse on a blog?
Because he cares. Because doing it right matters.
A point of clarification for those who may get here by using Dr. Google: If the NSTEMI is a type 2, i.e. not due to unstable plaque, then PCI may not be clearly superior to medical therapy.
I lack the knowledge base and experience to make an informed comment on cardiology per se. However, I know it takes guts to be an interventional cardiologist, and that it takes someone who truly cares about optimal patient outcomes to look at PCI, medical management, and patient-initiated measures side by side, as objectively as possible. And, I’m grateful that all options are readily available. Prevention of major CVD is of course best, but as Marty noted, sometimes you inherit a deck stacked against you; also, I’ve noted that patients’ own preventive measures can be incredibly difficult to initiate and maintain.
If I had a major blockage, I’d choose a stent procedure without hesitation. I’d do my homework in finding the right doc to do the procedure (as Dr. DS brought up), since I know of those who’ve been treated either by the unqualified or by the unethical (the latter group, I hope, is very small). But I wouldn’t tempt fate by waiting for meds and lifestyle changes to produce significant accessory circulation or any other critical improvement in my status. And if the physician I chose operated diligently but I still didn’t have the best outcome from the procedure, I’d still thank him/her for doing his best. No one can bat 1.000 over an entire career.
Just for the record, as an RN and healthcare grad student, I’ve had a few patients and two family members who’ve received great improvement in their ADL from PCI. They were informed of the need for further monitoring, possibly more (and more invasive) procedures, and definitely a need for better health habits plus lifetime medication. Good interventional cardiologists – and gosh, it takes a huge amount of dedication to get to that place – gave them the major start they needed to resume life in a different way. What happens from there is up to the individual, at least whatever is his or hers to control.
You’ve given much information and food for thought to those who, like me, are just learning about this very important issue. Thank you for taking the time, and making the effort. It really does make a difference. (But since you blog faithfully, you know that. Kudos!)
If the death rate is no higher with OMM than PCI, how are you tempting fate with the former more than the latter? At the very least, my opposite take – I would choose OMM without hesitation; why tempt fate by seeing whether I was one of the ones who would die or have a stroke caused by PCI? – is equally valid. Most Americans are primed to emotionally favor the high-tech treatment, assuming that it must offer some higher chance of “salvation” even when objective trials say otherwise; this can lead us to make decisions, or let them be made for us, that aren’t actually likely to further our interests.
My take has been shaped primarily by a family member’s experience; also, I’m going with my gut on this issue. Actually, my general preference is for OMM + lifestyle change. High-tech medical procedures don’t impress me until I see good results, and I certainly don’t let others make my decisions for me – although I know many people who don’t advocate effectively for themselves re. medical issues, so your point on that matter is well-taken.
When I think I have something to offer (and I’m learning more and more how careful I have to be about that), I counsel patients, friends, and family to explore their options, and choose the least invasive route based on the advice they trust the most. (“Invasive” includes a great many medications.) That’s a pretty basic outline: a lot of thought goes into my advisory process. I let people know that highly trained specialists can make mistakes, and I don’t try to force my own point of view on others. Ultimately, of course, you have to accept that differences of opinion abound, and oucomes vary greatly. I see your point and have no cause to quibble with it, especially since not even the experts agree, and even more so considering the agony your husband and you have been through. And I also hope for the best possible outcome for you both.
From a patient’s perspective, all of this can become very bewildering and confusing, especially when presented with different viewpoints simultaneously, and sometimes in a short time frame, without time to think the options through.
After my cath, the Dr, performing the cath spoke with me, as well as my cardiologist and a surgical team. The cath Dr, wanted to do a stent, the surgical team wanted to slice me open, do a bypass, a valve job and a maze procedure all at the same time, and when I questioned if I really needed all of this, the lead surgeon shrugged and didn’t really have a good answer except something like “we really won’t know until we go in”.
My cardiologist, after reviewing all of the notes and cath results said. “I’m not turning you over to the damn surgeons yet. We’ll handle this our way.” We did opt for a single stent, and a cardioversion and my continued lifestyle changes. So far, so good.
I’ve learned over time, from both my own, my extended family, and other’s experiences, that the best thing to do is get yourself to the point, if possible, with lifestyle modifications, to avoid treatments and procedures altogether, as one treatment usually leads to another – sometimes to fix the problems caused by the first treatment. This applies to many medical areas, not just cardiology, and not just to the field of medicine.
As mentioned, though, sometimes we are dealt a hand of genetic cards that cause us to have to fold early, and deal with the treatments. At that point, hopefully, the lifestyle modifications will keep the treatments and procedures down to a manageable level, and improve the outcome. We’ve see some pretty amazing generation to generation genetic predispositions when doing family research and connecting the dots.
As always, hindsight always trumps foresight. I know several people headed for trouble, and their answer to my concerns for them is always “better living through chemistry” or “they’ll be able to fix that if it happens – I’m not worried”. I was there once on several fronts – never again.
I think drugs and stents offer a false sense of security. I wonder how many people think a stent is a long term solution and believe that their problem is fixed forever, and don’t understand that without changes, the block can come back. I’ve heard often. “Oh, I’ve been stented – everything is fixed”.
No, the issue is not black or white, but instead infinite shades of gray.
My biggest area of disagreement with generally accepted practice is in the area of anticoagulation, but that’s meat for a different meal.
Oh, I could fume about anticoagulation as well. My husband is currently on rat poison awaiting a try at cardioversion, but we have resisted literally a dozen, often highly emotional attempts to shove him onto it for life. At first, he had a CHADS2 score of 2 due to moderate CHF and hypertension, so his cardiologist claimed he had an unmedicated stroke [actually stroke + TIA] risk of 4 or 5% per year – an estimate derived from a Medicare study of patients with a minimum age of 65 and a mean age of 80. He is in his early 50s. Stroke risk almost doubles per decade of age, including for people with AF, and age is a more potent risk factor than most of the CHADS2 components. We did not accept that this number could apply to him with no correction for age. He now has a putative CHADS2 score of 1, for hypertension – however, his in-office blood pressure is always between 80/50 and 120/80. We do not accept that his stroke risk is identical to that of a man whose blood pressure is 170/110.
Thus, we estimate that his stroke risk cannot be more than 1-1.5% per year. When he went off the warfarin he had been on for the first month or so of treatment, he asked the cardio, who was pushing him to stay on it, “How do I know it’s doing me any good?” and the guy (the best we’ve seen, by the way) said in portentous tones, “You haven’t had a stroke” – as if a stroke per month would have been likely otherwise! Also, lifestyle change including a plant-based diet was essential to completely reversing the heart failure he’d suffered, and as I keep trying to explain to various MDs, there is no such thing as a diet that is invariant, healthful, affordable, and palatable. You can have any three of those you like – not four. Which of the latter three do they expect us to sacrifice? If we sacrifice healthful, especially while he’s still on carvedilol, his weight would explode, and there’d be more than a 1% per year risk associated with that.
The senior cardiologist responsible for the malpractice my husband suffered, who also demanded lifetime warfarin during our few encounters, said to me: “I just tell my patients if you like steak, eat steak; if you like broccoli, eat broccoli. Just don’t eat steak one week and broccoli the next.” Now, aside from the question of what do you do if what you like is variety, or if you garden, I thought that if you have patients with life-threatening heart problems who like to eat steak every night, you should d*mn well tell them to learn to like something else. But that whole bunch of doctors was heavily emotionally invested in the dogma that patients never get better (indeed, at least two explicitly told my husband that lifestyle changes couldn’t help him, and as soon as they’d leave the room I’d scream “B******!!”).
While we are on the topic, let me offer another patient perspective.
Given a choice of a stent, or aggressive chemical treatment, I probably would opt for a stent.
I have yet to meet one drug for afib or cholesterol control that does not have significant side effects on me, and they lab rat-ed me on many. I’m sorry, but I don’t call them side effects any more – they are the EFFECTS of the medication.
I now understand why so many elderly people fall, are confused, have cognitive difficulties, sleep difficulties, break bones, bleed easily, have vision problems and are drowsy all of the time. It’s not because they are getting old – it’s what’s being done to them by meds. I think “side effects” are both under-reported and ignored far too often.
In reality, drugs are just controlled poisons your body has to deal with.
Do I have an ultimate answer – of course not. They are the only alternative in many cases.
This goes back to Dr. John’s first law of cardio-physics. Make yourself as well as possible with proper diet and exercise first.
Now. I’ll get off of my soapbox and listen to some Gordon Lightfoot while I work. And John, yes I own a copy of “Gord’s Gold”, one of my favorite quiet CDs.
That’s a very true and valuable perspective. At the same time, if you go on a statin and notice that your cognitive function is going downhill, you can always quit the statin and recover all or almost all function within a few months. (Admittedly, it’s not so easy to quit a rate control drug without which you can’t work or will develop heart failure.) If you have a PCI or CABG and notice the same thing, there’s no fixing it. After what has happened to my husband, our bias is strongly in favor of not letting doctors do things to us for which there’s no Undo.
Yes, Jane. It’s certainly many shades of grey. The Undo comment is spot on.
With some meds, there is no Undo though. With some it’s “whoops”. Part of the bigger med problem is the interactions and unintended consequences.
Don’t get me wrong – drugs can be miracle workers, and I intend to have an open mind about them when needed. I think the greater difficulty comes from poly-pharmacy, and over-prescribing. I double check every prescription I get just in case, and have caught several drug interactions that might have proved to have severe consequences. Experiences from myself and others have taught me that.
There’s risk to everything. My biggest risk of dying comes from the fact that I’m alive 🙂
My best wished to your husband and his upcoming cardioversion.