Look at this sample question from the American College of Cardiology self-assessment. Tell me whether you see the problem. (It came in a mass advertisement-email, so I don’t think it is a secret.)
A 75-year-old woman is referred to you with a murmur. She has had the murmur for many years and has been followed by her primary care doctor. Recently she has noted increasing symptoms of shortness of breath with exertion, but no angina or presyncope. A stress nuclear study is normal.
She is otherwise healthy except for mild hypertension. Her BP today is normal at 120/20 and she is in normal sinus rhythm. Her only medications are antihypertensive meds. On examination her murmur appears to be that of aortic stenosis. She has no clinical signs of congestive heart failure. You order an echocardiogram that reveals the following:
Echocardiographic report: Calcific aortic stenosis with preserved LV ejection fraction. Left ventricular hypertrophy is present and the LV chamber dimensions are normal. Mild mitral annular calcification is noted. Peak instantaneous aortic valve gradient is estimated at 56 mmHg with mean aortic gradient estimated at 30 mmHg. Aortic valve area by the continuity equation is 0.7 cm2.
You should now consider which of the following?
a. Surgical intervention with surgical valve replacement
b. Percutaneous intervention with a transcutaneous aortic valve
c. Balloon aortic valvuloplasty
d. Continued medical management for now
A hint: Look at the wording of the answers. I kept looking for the choice I would have made–choice ‘e.’ Nowhere in the possible answers was an option to present multiple different paths to the patient and let her choose the one that fits best with her goals.
We will have to foray into valvular heart disease for a minute. This 75 year-old women has a stenotic (partially blocked) aortic valve, which is the valve that lets blood out of the heart to the body. The valve area of 0.7 tells us that the degree of blockage is severe. (Think pinhole.) The three major symptoms of AS are shortness of breath, chest pain and syncope (fainting). And the best evidence suggests that patients with symptomatic AS live longer and feel better with valve replacement surgery. So, given how the question is written, letter ‘a’ correct.
My problem with the wording is that we are not given a choice to discuss different paths and align care with the patient’s goals. In this case, it is true that valve replacement surgery offers the best chance for a longer life and improved breathing. But open-heart surgery is significant. It means cutting the chest and heart open; it means exposing the patient to a 5-day hospital stay, with pain, less of autonomy and possible other complications. I like to tell patients considered for procedures that their disease may limit them today, but they walked in to my office under their own power. They are alive. There is always the risk that surgery or a procedures could render them worse. Risk from intervention may be low, but it is not zero.
The point is that patients vary in their level of risk aversion and goals for treatment. In this valve case, there is another path that the patient can choose: she might prefer to live with the disease and continue to reassess symptoms. Yes, living with the disease exposes the patient to the risk of death, but what if we presented the actual statistics and let the patient decide? Maybe this 75 year-old woman has different views of death than we do? Maybe her symptoms aren’t that bad, or perhaps she fears being in a nursing home more than death?
Don’t misunderstand, I want my patients to live long and well. In this case, if I were seeing the patient I would be clear that the path of surgery offers the best chance for a longer and fuller life, but the tradeoff in getting to that better place means accepting the (low-but-real) risks of surgery. I would also say that no one needs to have her chest cracked open. The path of no treatment is an option.
The practice of medicine, especially in this era of aggressive therapy, will be better when the correct answer to the question above is
‘e’: Aortic valve replacement offers the patient improved survival and better quality of life, but the best practice is to discuss the evidence, present multiple paths and align care with the patient’s goals.
We must get past the paternalism. In the span of my career, Cardiologists have always been leaders. Why shouldn’t we lead the way in shared-decision making and rationale use of our amazing tools?
Vanquishing the word “need” would be a god start.