The Selling of Heart Scans to People Without Symptoms
By Maryann Napoli

The unsolicited ad came in over the office fax machine. A local physician/entrepreneur was having a sale at a newly opened imaging center, offering: “2 for 1 Heart Scan….for each paid heart scan, your companion will have a free HeartScan.” The sale seemed to have the aura of an academic medical center about it. The letterhead and logo proclaimed University HeartScan and at the bottom of the ad, the word “Cornell” appeared in all caps.

For a cardiologist’s perspective on the wisdom of answering such an ad, we turned to Thomas B. Graboys, MD, who has provided several earlier important interviews about coronary bypass surgery and angioplasty. Dr. Graboys is an associate professor at Harvard Medical School and the director of the Lown Cardiovascular Foundation, which provides second-opinion consultations.

Dr. Graboys is one of the rare cardiologists who has written and spoken publicly about the rampant and inappropriate use of coronary bypass surgery and angioplasty. He is best known for advising people to have a second opinion before going through with a recommended cardiac catheterization because this diagnostic procedure is likely to be the first step toward an angioplasty or bypass surgery. An interview with Dr. Graboys follows:

MN: What do you think of the current trend toward encouraging symptom-free people to undergo these heart scans?

Dr. Graboys: It’s unconscionable. The decision to make an intervention on anyone without symptoms has to be based on the understanding that the test has been so carefully evaluated that the person doesn’t end up with false-positive results [erroneous evidence of heart disease], and this hasn’t been done.

MN: What are the risks?

Dr. Graboys: Further testing. There are inherent, though small, risks associated with these tests. For example, heart catheterization is not an uncommon scenario for people given heart scans. Patients have come to us, who had no symptoms. They had a heart scan which shows some calcium, and then a catheterization is urged. And then the patient has a complication of the catheterization. This is a remote possibility, of course, but cardiac arrest could result or an infection can occur where the catheter went into the groin. Everyone who is about to undergo this procedure has to sign an extensive form about risks.

MN: Do you see an upsurge in people coming into your center because they had screening heart scans?

Dr. Graboys: Yes. If a patient has no symptoms, it’s very difficult to rationalize intervening on them unless you have hard data to support invading their body with a catheter. What can you do with a person who has no symptoms? You can’t make them any better because they are already free of symptoms. You can only make them worse. When I see these patients who have had a heart scan, I have to think how I can psychologically decompress them. They tell me, “The heart scan suggests [the presence of] calcium in the vessels.” Doing a scan isn’t going to change the management. If you smoke, you have to stop. If your blood pressure or cholesterol needs treatment, you have to deal with that. So a scan isn’t going to lead to managing the patient any differently, except going the invasive test route.

MN: What is the significance of calcium in the vessels?

Dr. Graboys: There’s some new data that shows that calcium in the vessel doesn’t actually reflect a symptomatic narrowing. It doesn’t appear to be significant. By the time they hit 50, most males will have some calcium in the vessels. It sounds all very complicated, and it is.

MN: In a 1999 interview, you told me that the public should understand that heart disease is not a plumbing problem with clogged arteries that need to be opened with coronary bypass surgery or angioplasty.

Dr Grayboys: There are multiple avenues of explanation that help us understand heart disease. There is inflammation, or some type of bacterial problem [associated with the development of heart disease]. And there’s new work that has come out that takes away from the traditional approach, which is telling people, “You have 90% narrowing of a vessel and that’s a serious blockage, and now you need to have it opened with angioplasty or a stent.” Now we realize that a person is more likely to have a heart attack, if he or she has a minor degree of narrowing-let’s say, 30% of a vessel is narrowed. You would intuit that the patient with 90% would have a higher risk for a heart attack. But, in fact, that is not the case. A person is at a higher risk for a heart attack, if he or she has only a minor degree of narrowing.

MN: Has the word gotten out about the relatively new view of heart disease? You’ve been saying this for a long time.

Dr. Graboys: People don’t understand or believe it. And the reason for it is this: the person with the 90% narrowing has, over a long period of time, developed collateral vessels that go around the area of narrowing. Whereas, if a vessel ruptures in a person with 30% narrowing because he or she has high blood pressure, is a smoker, or has high lipids or clots that go to the heart, these patients haven’t developed enough collaterals to perfuse the heart. John Ambrose, who is at St. Vincent’s in New York, has published work about this.

MN: Has any organization provided guidance to physicians regarding the care of people with positive results from a screening heart scan?

Dr. Graboys: There are just not adequate guidelines for optimal management. [Doctors] are not sure what they should do with the information.

MN: Cardiovascular surgeons don’t seem to be following the long-standing guidelines about who should have bypass surgery or angioplasty.

Dr. Graboys: We’ve been taking care of people with coronary heart disease now for 30-40 years, ever since the advent of coronary bypass surgery. And we still haven’t reached closure about who should and should not receive these procedures, even though there are position papers from the American College of Cardiology and the American Heart Association. In academic circles, those guidelines have significant credibility, but that doesn’t necessarily translate into actual patient care. Regrettably, a large fraction of what we do in cardiology is economically based. A hospital puts up an open-heart unit or a catheterization lab. It has to get its money back, so the threshold for doing the procedures begins to lower; and the rationalization begins to increase.