I just found a way to save 25 billion dollars a year for President Barack Obama’s healthcare plans. That is to cut out angioplasty (currently called percutaneous coronary intervention, or PCI), for which multiple studies, including one in the June 11 edition of the New England Journal of Medicine, show are not useful for patients with stable coronary artery disease (CAD). The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack and death in people with stable heart disease doesn’t stop doctors from performing them.
In this procedure doctors put in a guideline in the coronary arteries and blow up a balloon that flattens plaque against the wall of the artery and opens up the artery or they insert a stent to keep the artery open. Sound good and makes sense, too bad it doesn’t work.
“There are people in the cardiology community who don’t believe the results. They don’t believe it applies to the patients they see,” Dr. Judith S. Hochman, director of the Cardiovascular Clinical Research Center at New York University School of Medicine, was quoted as saying. “So we still see a lot of angioplasty being done without patients really understanding that it will not reduce their chances of heart attack or death.”
But I’ll give the reason why they still perform 1.2 million of these procedures every year. It is pretty simple really. Greed.
Nancy Nielsen MD, President of the AMA, opposes healthcare reform
Doctors always say things like they don’t believe the data, or that isn’t the way it is in my practice. Since they won’t believe in science, data or reality, maybe we should just play their game and use some wizadry to get them to do the right thing and stop doing these useless procedures.
When I count to 3 you will stop performing angioplasties
Or maybe one of the Obama guys should have some guts and stand up and say we’re not gonna pay for those things anymore.
[Update: see comments section for reference to acute coronary events where PCI has demonstrated efficacy and citation by Marilyn Mann which was made immediately after I posted this on June 25 which I assumed was sufficient for anyone reading this; that didn't stop a cardiologist in another blog from going on the attack and saying that since the COURAGE trial showed lack of efficacy in reducing heart attacks in stable coronary disease these procedures have declined. Even so they are still estimated to be about 1/3 which is too many and some cardiologist lately have gone to jail for performing PCI on people with little or no heart disease. So my initial statement that 25 billion dollars could be saved is not correct. It is more like, um, 8 billion.]
You are correct, angioplasty (or PCI in cardiology lingo) does not improve outcomes in patients with stable coronary disease. That was also shown in the COURAGE trial.
However, it does improve outcomes for patients who have just had a heart attack.
Reference: Cantor, et al., Routine Early Angioplasty after Fibrinolysis for Acute Myocardial Infarction. NEJM 360:2705-2718.
http://content.nejm.org/cgi/content/short/360/26/2705
“Among high-risk patients who had a myocardial infarction with ST-segment elevation and who were treated with fibrinolysis, transfer for PCI within 6 hours after fibrinolysis was associated with significantly fewer ischemic complications than was standard treatment.”
A couple of years ago, there was a nuclear imaging test that could be performed on a patient experiencing a MI that could determine if PCI or thrombolysis would be most suitable for the patient based on this imaging test. The name of the test, I do not recall.
What is clear is that PCI provides no benefit to MI patients that are not in an emergency situation.
In other words, the MI that the patient is experiencing is not concluded to be severe or major. IV thrombolytic therapy is reasonable and necessary for such patients. There are about 5 agents to choose from in the thrombolytic category.
Nor does PCI provide benefits for the MI patients if the door to balloon time is over 90 minutes, or if the patient is not in an ER for angina within 4 hours of onset.
Interventional cardiologists, of course, choose intervention with PCI for treatment of a myocardial infarction. Yet these procedures are often not done on a post MI patient in the timeframe in which the PCI would be beneficial for the patient. Often, the PCI is performed 12 to 24 hours after the onset of a MI. The PCI procedure, I believe, is clearly unreasonable and unnecessary after that length of time.
Also, hospitals make between 20 and 20 thousand dollars from each PCI performed at their institution.
And about half the states do not find it necessary for such institutions to have on site open heart surgery backup for complications that could occur during a PCI procedure.
Such a complication may be a dissected aortic aneuryism, or another life threatening error that may occur during a PCI intervention.
“There are people in the cardiology community who don’t believe the results. They don’t believe it applies to the patients they see,”
——
That’s why surgeons (or any physicians) can’t be trusted to do research on their own patients.
I still say psychiatry has a better track record than all other fields of surgery in demanding evidence. It’s amazing how these guys strong-armed their way into making angioplasty a household word (and operation).
http://www.sciencedaily.com/releases/2009/06/090624193506.htm
When a PTCA may be more beneficial than thrombolytics with acute coronary syndrome patients:
The EKG shows a posterior myocardial infarction pattern.
Also, elevated acute ST segement elevation, with new left bundle branck block present, in which the Left ventricle’s delay allows the right ventricle to contract.
A Q wave MI has or will occur with these changes.
Unstable angina, wich indicates pain not due to cardiac muscle damage directly, is not due to cardiac muscle damage.
I’m the blogger you refer to in your update. I think another correction is in order here, just to settle any concerns about conflicts I might have: I’m NOT a cardiologist.