It’s a battle that has been raging thoughout the modern history of cardiology. Which is the best way to clear clogged arteries to the heart: bypass surgery or angioplasty with stents? Last week the latest study found that surgery still holds a slight advantage.
But wait! There's another option we hear little about: simply taking medication, changing lifestyle and not having either invasive procedure.
Some very smart doctors believe that the vast majority of the 1.6 million Americans who get these procedures in any year may never need the expensive and potentially dangerous interventions, or at the very least, they don't need them yet.
But we don’t hear much about option No. 3 because it is drowned in the tsunami of profits made with the procedures, especially angioplasty with stents.
Let me be clear, the vast majority of interventional cardiologists — the doctors who perform angioplasties — are honest and caring physicians. But I remember standing in scrubs outside a procedure room in Miami when the other doctors (who mistook me for a colleague) were bragging about how many “normals” they had done angioplasties on. That’s right, people came in complaining of shortness of breath or chest pain, so the doctors put them into the cauterization lab and examined their vessels, then told these patients they needed an angioplasty and did it knowing full well it was unnecessary.
For many doctors and hospitals, angioplasty has been the mother lode. I’ve had young interventional cardiologists brag to me of their multi-million dollar signing bonuses to change hospitals.
This specialty faces a mine field of potential conflicts because so much of it is based on self-referral. An interventional cardiologist diagnoses the blockage by injecting dye into the coronary arteries with tubes inserted from vessels near the groin. All too often the doctor will tell the lightly sedated patient he or she has one or more blockages, which can be taken care of right away with an angioplasty. That sure sounds great but it doesn’t always work. And there's no opportunity for the patient to weigh other options; no chance for a second opinion.
Angioplasty was first tried on humans in 1977, by inflating a tiny balloon on the wire that inserts the dye. But often the opened artery closes up again — a process called restenosis. Over the years doctors have tried to circumvent the problem by using the wire mesh devices called stents, either as bare metal or more recently infused with drugs that try to prevent the re-closing. Suffice it to say the efforts have not been entirely successful.
When a surgeon performs a bypass operation, the patient is almost always referred by regular cardiologist. So the dangers from self-referral do not affect this type of surgery.
But let’s go back to the radical notion that oftentimes neither procedure is necessary. For those with unstable angina, where the heart disease is rapidly getting worse, immediate treatment with one of these procedures is needed to restore blood flow to the heart. But most patients who have blockages in their arteries have what is called stable angina. They may be in discomfort but they are not in immediate danger.
One of the doctors who argued first and loudest that many angioplasties and surgeries were unnecessary was Dr. Thomas Graboys of Harvard Medical School. About decade ago, after years of struggle, he finally got the American Heart Association to allow him to present a seminar on the subject at its annual scientific sessions. Almost no one showed up. Few have an interest in the less profitable path. (Sadly, Graboys is now fighting a particularly aggressive form of Parkinson’s disease.)
Then last March, Dr. William Boden of Buffalo General Hospital in New York announced the results of a trial called by the appropriate acronym COURAGE. He randomized more than 2,200 patients with significant blockages. All were treated with heart medicines to control their cholesterol and blood pressure and minimize blood clots and were counseled to diet, exercise and quit smoking. Half of the participants also were assigned to get angioplasty.
After four and a half years there were slightly more deaths and heart attacks in the group that got angioplasty. Interestingly, the U.S. Veteran’s Administration and the Canadian Health Service — organizations interested in providing the best, but not necessarily the most costly care — funded the research. So far the impact of this powerful evidence on medical care has been minimal.
In fact the United States has twice the rate of bypass and angioplasties as other wealthy countries with no evidence of improved survival or less distress from heart disease. Any patient who is told he or she needs a stent or bypass surgery would be well advised to ask — from another doctor if possible — what happens if I wait?