Coronary Angioplasty, Stents, and Other Relics of the Paleolithic Age
In the next 24 hours, nearly 10,000 heart procedures will be performed in hospitals across the U.S. That's 365 days a year, year after year.
Procedures and drugs taking aim at heart disease appear to be getting better and better-yet the cardiovascular healthcare system grows bigger, generating more procedures, more expensive pharmaceutical agents, costly new devices. A day doesn't go by that most of us aren't assaulted with several TV ads, radio spots, billboards, and news reports of hospital heart care.
The cardiovascular healthcare system in the U.S. has mushroomed into a gargantuan industry. The American Heart Association estimates that over $313.8 billion will be spent in the U.S. on cardiovascular healthcare in 2009 (American Heart Association, Heart Disease and Stroke Statistics-2009 Update). The U.S. Department of Health and Human Services projects that total health care spending will double to $3.6 trillion by 2014, consuming 18.7 percent of the nation's economy. Cardiovascular care is the largest piece of the total healthcare bill. The system grows, pulling more and more Americans into this hungry procedure generating process that maintains an insatiable appetite for more.
Just what are we getting for our $318 billion? How much of it is truly necessary or beneficial to us? How much is performed for the benefit of the doctor or hospital?
Hospital heart procedures - What is accomplished?
Hospital heart procedures like balloon angioplasty, stent implantation, atherectomy, coronary bypass surgery¾all the procedures for coronary disease - restore coronary flow when flow is reduced.
Quite simply, during heart catheterization (the starting point for all major heart procedures) access into the artery system is gained through the leg (femoral) or arm (brachial or radial) artery, pre-formed catheters passed through the aorta and to the heart. Catheters are used to both inject x-ray dye as well as pass equipment, such as wires that act as a "rail" system to pass balloons, stents, cutting devices, and other tools for dealing with the various configurations of atherosclerotic plaque in arteries.
If the anatomy is unsuitable for angioplasty and related procedures (e.g., blockage located at a difficult branch point, or involvement of the left mainstem, a potentially hazardous area for stents) then bypass surgery might be considered. In this case, the mammary artery from within the chest wall or a leg vein is "harvested" and used as an alternative conduit for blood flow.
In other words, if there is a 70% blockage or more and there is evidence for poor blood flow to that segment of the heart muscle (suggested by symptoms like chest pain or breathlessness), an abnormal stress test showing poor flow to one or more segments of the heart, or an area of abnormally reduced strength of the heart muscle (e.g., on an echocardiogram), then there is potential benefit to restoring poor blood flow by expanding a rigid stent that scaffolds the artery open. This is because poor blood flow to the heart can be dangerous and trigger unstable heart rhythms.
For example, someone goes to the hospital having chest pain but not having a heart attack and undergoes a stress test. An area of reduced blood flow to the front half of the heart is discovered. Stent implantation in the artery to this area, or a bypass graft, may indeed provide benefits by relieving symptoms, removing dangerous effects of reduced blood flow, may even reduce future risk of heart attack and death. Someone who is having a heart attack also benefits from heart procedures performed urgently.
The mechanics of heart procedures are well worked out, having been repeated millions of times across the U.S. over the past 20 years.
What is not clear, however, are the benefits of heart procedures in the following situations:
1) No symptoms but with an area of poor blood flow by stress testing
2) No symptoms but with coronary plaque identified through a heart scan (a positive heart scan "score")
3) Just to see whether heart disease is present because you or the doctor wants to know. (This is a surprisingly common reason.) A common buzzphrase among cardiologists is "to define coronary anatomy."
4) Chronic (months to years) symptoms of chest pain or breathlessness with or without an abnormal stress test
The benefit of heart procedures like stents are being called into question even in patients with symptoms of chest pain and abnormal stress tests. The recent COURAGE Trial of 2200 participants, all of whom had coronary disease, observed over 3 years showed no difference in heart attack and death between two groups: 19% in those undergoing stent placement vs. 18.5% in those receiving "medical therapy," although a third of those in the latter group "crossed over" to receive stent(s) or other heart procedure for deteriorating symptoms during the 3 years. This has put a major damper on performance for heart procedures across the U.S., with a sharp reduction in usage in the past year.
Think of it this way: No study has every shown that procedures like stents or bypass surgery prevent heart attack or death¾except the one you're about to have. Procedures therefore are helpful when the plaque in the heart's arteries that has already "ruptured" can be pinpointed and flow restored, either through stent implantation or similar procedure. But stents or bypass of, say, a 50% or 70% blockage, or of multiple blockages, that are chronic has not been shown to risk of heart attack, nor provide advantages in survival.
Heart procedures can be beneficial, no doubt about it, particularly in acute settings like heart attack or rapidly deteriorating symptoms. However, the lack of proof of benefit, despite 20 years of intensive application, should give us pause in accepting the "stent or bypass everybody" mentality that often operates.
The overselling of hospital heart procedures
On my daily 25-minute highway commute to the office, I pass two billboards advertising heart bypass surgery, each from a different hospital system. One features the smiling faces of hospital personnel in scrubs, the other a patient beaming with satisfaction proclaiming Hospital XYZ as "his" heart hospital.
Why do hospitals run such ads? They are surely not cheap, often costing tens of thousands of dollars every year.
It takes a lot of money to build and sustain a hospital heart program: add a $2 million heart catheterization laboratory or build a new $40 million hospital wing. Heart procedures are the number one source for revenue in hospitals, their big seller, the source of the millions of dollars for increasing executive pay, perks to important doctors, and expansion. Without heart procedures, hospitals would be far fewer and a lot smaller.
Cardiologists have also made a lucrative practice out of heart procedures, many devoting themselves exclusively to procedures and nothing else.
When I was younger, I trained specifically in hospital heart procedures. That's what I was trained to do, that's what I did in the first 5 years of my practice, often performing 5-10 procedures every day, morning ‘til night. Having performed thousands of procedures, I know intimately how the process works.
But, after several thousand procedures, it became clear that procedures are nothing more than a very fancy "BandAid®" - little is gained long-term in the majority of patients who receive stents or undergo bypass.
Prevention of heart disease? Well, that's the part that often gets forgotten, with anything beyond a prescription for a statin drug felt to be unnecessary or excessive. Yet that is the key: prevention is the answer to heart disease, not procedures. How powerful is prevention? Extremely powerful. In fact, I would go so far as to say that, when the right steps are taken, prevention is more powerful than procedures outside of acute situations.