Tonight, I am going to stick up for my interventional cardiology friends. These are the good folks who respond immediately (and I mean immediately) when you have a heart attack. They open clogged arteries. Like Jack Nicholson said, â€œyou want these guys on the wall.â€
Why do I feel the need to take up for the apex-predators of Internal Medicine?
Because bio-statisticians and academics are trying to make treating heart disease seem way easier than it really is.
Take this most recent meta-analysis (Archives of Internal Medicine) of stents versus medical therapy in patients with â€œstableâ€ coronary disease. The researchers pooled multiple previous trials where stents and meds were compared and found no difference in outcomes. (Detailed summaries are available on TheHeart.org and Cardiobrief.) Itâ€™s not intuitive to think that stenting open an artery (sometimes from 90% to 0%) does not reduce the chance of death, future heart attack, or unplanned heart surgery. But this data looks very real.
Adding to the piling-on effect was an invited editorial from Dr William Boden, the lead author of the Courage Trial, which just so happens to be the â€˜landmarkâ€™ study of meds versus stents. In 2007, in the NEJM, Courage investigators concluded “PCI [stents] did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.” Asking Dr Boden how he feels about this meta-analysis is like asking me if the double Ironman is dumb. Of course, Dr Boden thinks treating blockages with stents is overrated.
Let’s insert a real world view:
The reality here is that treating major blockages in the heart (as if there were such things as minor blockages) with only medicines constitutes very aggressive and risky behavior.
Consider these common scenarios:
A patient presents to the emergency room with atypical, fleeting and clearly non-heart-related chest pain. Or perhaps a marathoner wants a stress test; or a diabetic patient needs pre-op clearance.
Unless a patient’s risk of heart disease approaches zero, a rarity, they get referred for further testing, which means looking for blockages. Remember, there is no room for being wrong–none. Perfection. Never be wrong.
So, the patient comes for a stress test. â€œMaâ€™am, we are doing this test to look for blockages.â€
Alas, the stress ECG looks a little funny. Suspicions arise. Never comes up again; never be wrong.
â€œMaâ€™am, your stress test is positiveâ€¦I think you should have a cath…This is a test where we look for blockages in the heartâ€™s arteries.â€
Heart doctors usually recommend looking for blockages after positive stress tests because untreated major blockages may lead to bad outcomes, like death.
The consternation starts when the cath shows an 80% blockage. Before the meta-analysis and trials named Courage, a heart doctor would squish and stent the blockage and render the artery 100% clear, or 0% blocked. That part of the heart gets more blood; the patient feels fixed; the doctor declares victory.
Both the general public and the majority of the medical world view this scenario as ‘normal.’ The story is told in doctors’ lounges, on golf courses and even on bike rides. “My heart doctor fixed my blockage.”
What the public doesnâ€™t know is that 80% blockages arenâ€™t often the ones that will cause the future heart attack. Rather, heart attacks come from the 10% blockage that gets nary a mention, or is called a minor blockage.
Back to medical therapy: the reason why lowering cholesterol with statins, treating high blood pressure, using adrenaline (beta)-blockers and instituting lifestyle changes can produce equal outcomes to stents is that such measures target the disease of atherosclerosis at its root, whereas stents just fix the end-result.
Ahâ€¦But here is where real life makes it tough to implement such an academic strategy. Itâ€™s very hard to walk away from an 80% blockage. What do you tell your patient if she wants to run, or play tennis? What about the next time someone cuts her off in traffic and adrenaline levels surge? What if it was your left anterior descending arteryâ€”you know, the â€œwidow-makerâ€ artery? Finally, imagine explaining to the primary care doctor that it was a good idea to leave the artery 80% blocked? Iâ€™m not sure about how things roll in Boston and Hanover, but this would be a tough sell in Kentucky.
My eye-surgeon friend said it well when she noted how stressful it would be to work on the heart. Why? I asked. “Because people have two eyes but only one heart.â€
Iâ€™m putting my money down that aggressive targeting of atherosclerosis, not just with pills, but strict attention to diet, exercise and behavior modification, could indeed equal stenting. But there are a lot of unknowns with this strategy:
Will the US ever accept a healthcare system that allows doctors not to exclude everything possible? Maybe then we could stop doing so many stress tests and caths?
Will heart patients ever be expected to help themselves? Could a recommendation to stop smoking, eat less, exercise more and take a few basic medications be considered adequate medical treatment for a blockage? Or will such advice continue to be labeled as mean, unfeeling and not doing everything?
And hereâ€™s a biggie question:
How many of the 23 authors of Courage would accept medical therapy of their 80% blockage once they saw it?