Wednesday, March 13, 2013

Cardiac Outcomes

Alice Park reviews David Jones' counter intuitive new book on the history of cardiac surgery and coronary angioplasty in most recent issue of Harvard magazine.  Jones, also a physician, is a professor of medical history at Harvard.  His latest book explores the rise of interventional cardiology and cardiac surgery since the 60's and how much of the rationale for such a procedure-dominated treatment strategy is undergirded by some surprisingly shoddy data. 
The first randomized clinical trial of bypass surgery’s efficacy, using data from a collaboration of Veterans Administration hospitals, was not published until 1977. Such trials were then becoming the gold standard of medical research (and still are). “Surgeons said trials were totally unnecessary, as the logic of the procedure was self-evident,” says Jones. “You have a plugged vessel, you bypass the plug, you fix the problem, end of story.” But the 1977 paper showed no survival benefit in most patients who had undergone bypass surgery, as compared with others who’d received conservative treatment with medication.
It's funny, coming from the perspective of surgical training, I don't recall ever hearing from disgruntled cardiac surgeons the actual reasons why bypass surgery had started to fall out of favor during the nineties and oughts.  All I heard was that fellows were having a hard time scoring jobs because bastard cardiologists were snaking all the cases.  Never did we discuss studies outlining the lack of survival benefit from CABG.  It seems obvious now that such an inquiry was a trip down the existential rabbit hole--- no one wanted to find out that the profession one had spent a third of one's lifetime preparing and training for was, in the end, no better in terms of providing survival benefit than simply telling someone to stop smoking, to eat better, and to get off the couch. 

Cardiologists come off no better in the piece.
In 2007, a study of more than 2,000 patients with stable coronary disease showed that compared to drug therapy alone, stents in combination with drug therapy such as blood-pressure medications and cholesterol-lowering agents did not lower the risk of having a heart attack or improve survival during a seven-year follow-up period. But instead of curbing stent use, two years later, a survey showed that the share of patients receiving drug therapy merely as a first-line treatment, before getting stents, remained unchanged at 44 to 45 percent
We may be too far gone to change anything.  The coronary intervention/surgery sector is a $100 billion industrial complex.  It won't just fade away like the open cholecystectomy or peptic ulcer surgery.  We've successfully propagated this myth that all cardiac procedures are life saving. It is the economic engine that drives many hospital systems.  Some myths have staying power, especially if your 5% profit margin is riding on its continued perpetuation.....


Anonymous said...

I'll just go pop some popcorn, be back in a minute :)


Anonymous said...

I always thought something was extremely fishy about people being whisked away for immediate CABG surgery after an angiogram showed some completely non realistic percentage blocked. Pfff!

I mean really! If the blockage was really 95%, there's no way they'd be alive right there. Even if it was something more reasonable, like 94%, the fact that they don't put in a stent and opt for CABG is the real smoking gun!

What really galls me is the Stents!! All of these people going from death's door to feeling normal in 4 hours is just galling! It gals me to no end that they could feel just as good with some medicine and a anaerobic workout regimen of 440 intervals to get that heart muscle back in shape!

While we're at it, let's get rid of mammograms. Studies show that the overall negative impact of false positives outweighs any overall good. The better approach is to let the ladies with undetected cancer die in order to save all of the false positives the hassle.

Oh, and finally. Let's get rid of ionizing radiation in medicine. Do you know how many people are injured or killed each year by incorrect x-ray dose compared to workers in the nuclear power industry?

Jeffrey Parks MD FACS said...

your sarcasm comes across loud and clear, but rather ineffectively. did you read the article?