Five “real” world issues with the complex decision to recommend heart catheterization…

Malpractice and heart catheterization are in the news today.  A spicy concoction for sure.   An epidemiological study published in an obscure online (and overpriced) subsidiary of Circulation addresses the role of three major medical issues facing cardiologists today: malpractice, heart catheterization, and medical costs.  The summary details of the study have already been published in many different sources. The best review is here.

It is hard to get more controversial.

Heart catheterization, the invasive assessment of the coronary artery lumen, has always been a hot-potato topic.  The “percent-normal” was the buzz word when I joined private practice 15 years ago, and even now, much is written on the potential overuse of heart caths.

Heart disease is the leading killer of humans.  Mostly, it stems from luminal obstruction of  the heart’s blood supply, the coronary arteries.  By injecting an opacifying contrast dye directly into the coronary vessel, a heart cath reveals the presence or absence of obstruction.  The severity of obstruction, its location, and morphology is combined with symptoms (at least it should be) to formulate a treatment plan.  In addition to lifestyle improvements, only three options to treat blockages exist: medicine, stents and bypass. The heart cath is essential in deciding.

Are too many done?  If so, then why?

Even for a budding master of the obvious, the decision to recommend a heart cath is frequently not an easy one. There are many complex issues.  Here are just five…

Issue 1: Consequences of being wrong are substantial.  Missing severe heart disease is dreaded.  Not just the fear of malpractice, but also, the fear of simply being wrong, and that this error could cost a human-life. There is a strong incentive to be sure.  As is frequently the case in American medicine, not doing the invasive test is the more aggressive course.

Issue 2: Anecdotes of atypical cases are abundant.  We have all seen the seemingly athletic patient, with a false-normal stress test, show severe multi-vessel disease despite having zero symptoms.  Remember: in one in five patients, the first manifestation of heart disease is sudden death.  Our present-day decisions are always affected by past cases.  On the other side of the coin, is the high risk smoker, who is overweight and diabetic, but despite a positive stress test has normal arteries.

Issue 3: Non-invasive imaging tests are fallible.  They are wrong infrequently, but enough to always muster a shred of uncertainty.  Consider the wealthy man with the mid-line chest scar, I met at a pool in AZ, who told me of his severe chest pain.  The severe pain prompted evaluation at a regional branch of nationally recognized health care provider in Scottsdale. By his report: the hospitalist ordered a stress thallium exam.  It was read as normal.  The request for a cardiologist opinion was denied and he was discharged.  After the pain recurred the next day he went elsewhere, saw a cardiologist who recommended an immediate heart cath.  All three vessels were critically narrowed and bypass was done emergently.  His example illustrates a paradox of stress testing: when all three coronaries are equally blocked, a thallium stress exam can be normal–balanced ischemia. The patient knew of this paradox from his internet reading, but mysteriously his first doctor did not.

Issue 3a:  Recently developed stress imaging procedures like PET scans are much more specific and sensitive.  They are wrong less often and expose the patient to far less radiation.  You guessed it, PET is more expensive and even though superior, they are often deemed prohibitively expensive, and thus frequently denied by the profit-conflicted third party controllers of care. Sorry, this is a fact of life.  And this tug-of-war between superiority and higher costs of newer technology is only going to get worse with upcoming health-care reform.  Buckle-up.

Issue 4: A heart catheterization is relatively safe and painless–except the disasters which are hard to suppress from your memory.  She was a busy professional with an innocuous, but bothersome arrhythmia. A heart cath is done because of a false-positve stress test.  She has no chest pain, no risk factors for blockages, but some cardiologists feel that using certain drugs for AF mandates proving a lack of blockages with nuclear tracers, rather than common sense.  Her right coronary is dissected, an iatrogenic heart attack ensues, and now a decade later the scar persists.  This complication is fortunately a very rare phenomenon. Because stories of missed heart disease far outnumber those of complications, it follows that most doctors lean towards looking.  Again, the decision not to cath is a far more aggressive one.

Issue 5:  Money. It is true that we are paid for performing a service–like the dentist or lawyer.  Many cardiologists have cath labs in their office.  The “technical” portion of a heart catheterization bill–that much higher reimbursed portion that the hospital usually gets–is captured by the cardiology group.  This isn’t bad.  The group invested its own money in the capital outlays, pays many employees, provides a much more cost effective procedure, and provides equivalent quality.  No worries though, the much ballyhooed privately owned cath lab is increasingly becoming irrelevant, as more cardiologists are partnering with the competing hospital.

Issue 5a:  The prominent lawyer who is also a friend writes me, “my insurance company only payed (my partner) 260 dollars in professional fees for my heart cath”   For the record, that’s one fourth of a root canal.  The whole self-referral-incentive argument seems a bit weak when a heart cath is reimbursed less than a root canal.

To the head-line promoters and doctor critics, I say that the heart catheterization decision is far less clear than many non-clinicians make it out to be.  The fear of legal liability is only a small factor in a complex decision making milieu where human life lies precariously in the balance.

The 260 dollar professional fee “allowable” for diagnosing a life threatening disease seems even less enticing than the industry sponsored ink-pen.

JMM

3 comments

  1. A know a cardiologist who is convinced that "you're more likely to get sued for doing nothing than for doing something."

    He's criticized for doing too many heart caths, yet I've seen too many patients with squirelly, atypical chest pain that have turned out to have major coronary heart disease when cathed.

    -Steve

  2. i recently had a 32 yo with a widowmaker. no fh of premature cad. apparently his heart didn't read the books.

    dr john, could you comment on how you screen for cad in patients on 1c agents as they age. example: pt on flecainide started at age 55, now age 75 and flecainide is still working, no cad. normal ekg, normal heart function on echo. do you stress them? how often? for discussion sake, let's say that their spouse, same age, same history except that at age 70 the spouse developed a left bundle. how do you handle that differently? thanks!

  3. Steve,

    Your words reinforce my thesis. Thanks.

    Anony,

    As all doctors are, I am influenced by past experiences. In fellowship at IU, all EP fellows saw patients with Dr Zipes. This, in the era right after the CAST data. Encainide was felt to be poisonous, but yet there were patients–many with ischemic cardiomyopathy– who year after year would come in for the encainide or moricizine refills. THese drugs were started way before CAST. I would ask about the obvious dilemma of whether we should stop the drug because we know it is bad statistically, even though this particular patient with heart disease continues to do fine for decades. (Note: This is not an advocacy for IC drugs, rather just a description of important experiences.)

    With that backdrop, I do screen patients periodically for structural heart disease with: office visit (history), ECG and the stress test least likely to have a false positive–stress echo. I am advantaged to be in a group of 8 other cardiologists and a technically proficient ECHO lab. As patients age, I watch the QRS width closely. Aging decreases drug metabolism, and lower doses sometimes suffice. Stress tests every few years seem sufficient in the low risk patient, but I agree strongly with the notion that it is important to rule out significant structural disease in the initial phases of starting the IC agent.

    I am cautious with IC drugs in all patients, but especially those with conduction system disease. LBBB impresses me. Do I have patients on Flecanide with LBBB? Yes, but not many.

    Thanks

    JMM

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