Unnecessary Procedures

Several recent articles, published earlier on this website, discussed the  excessive use of cardiac catherization and stenting in the evaluation and treatment of coronary artery disease.

Despite guidelines, issued repeatedly by the American Heart Association for evaluation of patients suspected to have heart disease, it is not uncommon for these to be ignored.

A recent article published by Patel et al. in the NEJM showed that in 60% of non-urgent or emergent cases, cardiac catherization, performed as a “shot in the dark”, resulted in the finding of normal (i.e. no blockages) coronaries. In another study 30% of cardiologist indicated they would order a cardiac catherization for other than clinical indications.

As part of a routine pre-procedure authorization, patients are frequently asked to allow for placement of a stent if a blockage is found. Most patients will agree to such a request, resulting in the placement of unnecessary stents in 30% of procedures.

What does this mean?

• Every procedure has its own built-in risks & benefits. If done for the wrong reasons, a patient is only exposed to the risks involved.
• A stent destroys the coronary artery locally, occasionally blocks important side branches and often sends debris downstream, damaging the very heart muscle it intends to protect.  Once a stent is in place, expensive medications are needed to keep it open, despite of which there is a more than 10% risk of closure within the first year.
• If you undergo catherization for the wrong reasons and allow for placement of a stent “as long as we are there anyway”, you are on a slippery slope, where you from now on need to be treated for a new disease (your stent), probably requiring more stent placements to fix the one that is going to fail.
• Coronary artery disease is part of an industry where stenting alone generates 15 Billion $$/year in the US alone. Unlike coronary artery bypass grafting (CABG), stenting has not been shown to improve life expectancy, except in some patients with an acute heart attack.
• During the last 10 years, CABG has been reduced to a rarely used solution for treatment of coronary artery disease, used only when a stent placement has failed or proven impossible. There are numerous reasons for this, some of which include a (very natural) fear of pain and possible complications on the part of patients. A major reason however may well be that there is an enormous financial incentive for a cardiologist to keep treatment in-house, referring to a partner rather than another specialist and heavily supported by a for-profit medical industry.
• When used appropriately, stenting is an appropriate tool in the arsenal of treatments available for CAD. If not, it is just another way by which health care costs have reached stratospheric levels.

What can you do?

• If you have new symptoms, especially if they are typical of angina, you need to see a doctor now!
• If it is not an emergency, you have time enough to go through a proper evaluation.
• There are a number of logical steps that lead to elective cardiac catherization, such as proper evaluation that should at a minimum include an EKG and a stress test.
• Older men are at a higher risk for heart disease than women of the same age. So are diabetics.
• Take the “calculate your risk for heart disease” test. If your risk score is high, you are more likely to have coronary artery disease.
• Women get heart disease even before menopause, but often have atypical symptoms such as unusual fatigue (“tired all the time”), particularly if smoking and/or “metabolic syndrome” is present. Women often have smaller caliber coronary arteries as compared to men, making stent placement riskier.
• There is place for medical treatment, diet and exercise as the primary therapy. In fact, irrespective of whatever intervention is chosen, none should be given in isolation of these three.

Tell me what you think,
Dr T