Angioplasty Overuse and Bill Clinton
Posted by medconsumers on February 25, 2010
Bill Clinton’s recent treatment for “chest discomfort” focussed the public’s attention for at least a week on the nation’s most frequently performed (i.e., overused) heart procedure—angioplasty. Yes, propping open a clogged artery with stents will immediately stop the discomfort, as the former president noted in interviews. It’s faster than drugs and the death rate from the procedure itself is low (under 1% in New York). The average cost is $15,000.
But a significant number of people who undergo this procedure each year will do just as well on multiple-drug therapy—the same drugs just about everyone is told to take after angioplasty. This was shown in a landmark trial known as Courage, which involved only people with stable heart disease. When results were published in the 2007 issue of The New England Journal of Medicine, they made headlines across the country and stunned many an interventional cardiologist. At the time, researchers estimated that 30% of the people currently receiving angioplasty can just as safely be treated with drugs alone. Quite reasonably, the number of angioplasties would be expected to drop accordingly. But, as the Wall Street Journal reported recently, the 250,000 angioplasties done yearly decreased only in the two years after the 2007 Courage results were published. After that, it was business as usual. And business is the right word as interventional cardiologists make an average annual income of $500,000.
The Wall Street Journal article states, “Sanjay Kaul, a prominent cardiologist and researcher at Cedars-Sinai Heart Institute in Los Angeles, estimates that the U.S. could save $5 billion of the $15 billion it spends on stent procedures each year if all doctors followed Courage’s guidance—that is, putting certain heart patients on generic drugs and turning to stents only if the pains persists.”
What we need now is more public clamor for meaningful informed consent (as opposed to the hospital-generated consent form). How informed are the heart patients who arrive scared at the E.R. with chest discomfort or chest pain? Are they told about the drugs-only option? Is the $500,000-a-year interventional cardiologist the right one to provide the pros and cons of each option? And lastly, are people told beforehand that angioplasty and coronary artery bypass surgery are not cures for heart disease but stopgap measures, as Clinton’s story aptly illustrates. The former president had a quadruple coronary-artery bypass surgery in 2004 and it was an artery newly grafted during that operation to improve blood flow that had closed up.
There’s hope, though, for fans of informed consent. At least one team of researchers is experimenting with novel ways to inform (warn?) the public. The Boston-based Foundation for Informed Medical Decision-Making has developed educational materials that describe the pros and cons of each heart treatment. It is currently being tested in a pilot project aimed at primary care physicians. The decision-making materials are provided to prompt doctors to initiate discussions with their patients at high risk for heart problems. In other words, the program changes the location of where the information is imparted and encourages doctors with no financial stake in the patient’s decision to talk with their patients about treatment options well before symptoms start. Patients are encouraged to discuss their understanding of the educational materials with their primary care physicians. The idea is to be fully informed about treatment options way before the first visit to a heart specialist.
Lifestyle changes such as smoking cessation can be more important than drugs in reducing the risk of heart disease. Exercise needn’t be more than a 45-minute walk five days a week. Read my 2008 interview with Dr. Steve Blair (“You can be fat and fit”) whose research showed that’s all you need to improve cardio/respiratory fitness. And for the many people who need help recognizing which foods are healthy, there’s the new, slim book by Michael Pollen called Food Rules. A 30-minute read, the book expands Pollen’s initial dictum: Eat food. Not too much. Mostly plants.
The country’s only second opinion service for angioplasty: Read this about the Lown Cardiovascular Center.
Maryann Napoli, Center for Medical Consumers(c)