Overtreating “Heart Conditions”

We have already written about the excesses of some of today’s interventional cardiology practitioners, who really believe in what they are doing but have not demonstrated any decline in mortality from the placement of millions of stents. In fact, even the popular press has picked up on this. David Epstein’s article in the Atlantic is a great place to start. The article makes a strong case that it would be wise to keep these devices—stents that can never be removed and require patients to take blood thinners after they are placed—out of your body except in special cases.

Of the many clinical studies I reviewed on the topic, only one took the time to consider the conservative, noninterventional possibilities that might play into a decision to use a stent. These include risk factors like the probability of restenosis around the stent, requiring yet another intervention, or the upside possibility of the heart creating its own new capillaries to supply extra blood to the muscles that are starved. This is an amazing process, known as angiogenesis, in which your body grows new capillaries to resupply an area that has less blood than it needs long-term.

If you are having a serious heart attack, the almost universal advice is a balloon angioplasty or stent procedure. It’s often lifesaving. But for treatment of partial blockages or prevention of a heart attack, the science on this highly invasive procedure is just not there.

The interventional cardiologists’ view of heart catheterization and stent placement has gotten so favorable and so simplistic that they sometimes miss the fact that coronary arteries can contract and spasm during angiography and produce what looks look like a blockage on the fluoroscope, leading to unnecessary stent placement. This is outrageously harmful medicine.

Then there is the heart bypass operation— known to the profession as revascularization or coronary artery bypass graft (CABG). This operation, sometimes characterized as the best of American medicine, has declined in frequency from its peak in the 90s, but it is still practiced on over 200,000 patients per year in America. It is such a part of American medical lore that one hesitates to say anything even mildly critical of it. If it were a political candidate running against conservative heart treatment, it would win in a landslide. But here’s what Dr. Nortin Hadler, professor of Medicine at the University of North Carolina at Chapel Hill, says:

CABGs should have been relegated to the archives fifteen years ago, but they have not been … the cardiovascular surgery community continues to announce a demonstrated 20% improvement in survival benefit (a 20-year-old study) but seldom the fact that the benefit pertains only to the 3% of all heart patients with special left artery blockages. The surgical community does little to forewarn us of the demonstrated downside of these procedures: the anguish of the multiple cardiac catheterizations required before surgery; the painful and difficult challenges of healing and recovery; the 2-8% who die on the table or in the post-operative period; the 50% who suffer emotional distress, mainly depression, in the first six months; the 40% who still have memory loss at a year; and the alarming number (depending on their level of activity before the CABG) who never return to the workforce or describe themselves again as well and enjoying life. For some, dementia is the only clinically important result of having their coronary artery anatomy successfully rearranged. For none is the likelihood of survival improved.

In reply to such criticism, the cardiovascular surgical community replies that the CABG technique has been refined since the old trials. Patients are doing so well, surgeons claim, that there is no need to repeat the three now-dated classic trials that compare surgery with medical therapy.

I would sum up this excursion into the evaluation of aggressive interventional cardiology by just saying to our family and friends: be careful, get the facts, and understand today’s huge bias toward action. If a cardiologist says to you, “In view of what you’ve told me about your lack of exercise and your cholesterol score, we need to do heart angiog- raphy on you,” consider saying no thank you. You need to find someone who will think more conservatively and start with a simple noninvasive test—like a stress test on a treadmill, combined with an EKG and a simple sonogram of the heart, called an echocardiogram, for instance.
In summary, we should all celebrate the leadership of American cardiologists and surgeons in treating advanced heart disease. But some heart treatments today fall into what Dr. Hadler, tongue in cheek, calls “type II medical malpractice”—the act of doing something to you very well that you did not need in the first place! Especially if you are a middle-aged male, you are vulnerable to becoming a heart patient for reasons that are not medically valid.