Monday, September 30, 2013
Stinting on stents
Former President George W. Bush underwent an angioplasty, and the details sparked a public debate about the controversies of heart disease treatments.
His spokesman stated that he underwent a routine physical exam and had no symptoms of heart disease. A stress test showed EKG changes and a CT angiogram found a blocked artery. He was transferred to another hospital and underwent an angioplasty, a procedure in which a stent (a wire mesh tube) is inserted into the blocked artery and pushed against the artery walls to prop it open.
Before delving into the details of the ensuing controversy, let me make clear that we don’t have enough details about Bush’s care to make any judgments about it, and the rest of the post will be about angioplasties in general, and not about Bush’s case specifically.
Whenever a public figure undergoes a medical procedure there is a concern that the public will misunderstand the details and assume that the procedure is also right for them. (A recent example is Angelina Jolie’s revelation of her double mastectomy.)
The controversy regarding Bush’s care centers on the fact that while angioplasties are known to be lifesaving during or immediately after a heart attack, in patients with stable heart disease they have no advantage over medications other than for relief of chest pain. We are told that Bush was not experiencing chest pain, and he is known to be an active athlete, having hosted and participated in several lengthy bicycle rides since leaving office. So the justification for the angioplasty is unclear.
Our best evidence comparing angioplasty to medications in patients with narrowed coronary arteries comes from the COURAGE trial which published its findings in 2007. The trial showed that rates of heart attack and death were the same whether patients with blocked arteries underwent angioplasty or were put on optimal medications.
This is where the media sometimes distorts the story. The press coverage of Bush’s angioplasty had frequent questions about the necessity of the angioplasty and the cost of such a procedure. That is precisely not the point, and gives the public the incorrect idea that angioplasties are expensive and beneficial luxuries. BMWs, after all, are unnecessary and expensive, but very nice. And if a VIP gets something unnecessary and expensive, shouldn’t I want one too? The point of the evidence about angioplasties is that in most patients they have no benefit. Focusing on “necessity” misses that point.
It is entirely possible that Bush’s care was flawless. One possibility was that his stress test was extremely abnormal. Such very abnormal tests were excluded from the COURAGE trial, and we have no definitive evidence whether medications or stenting is best in those cases.
The important thing for the public to understand is that VIPs sometimes get terrible care. I’ve personally seen that myself. Physicians often over-test and over-treat celebrities, wrongly thinking that this will protect them from blame for any adverse outcome later. It’s much easier to tell a prominent patient that we will fix your problem with a high-tech and very expensive solution, rather than taking the time to educate the patient that we should start a few very old and very inexpensive medicines which have been proven to save lives. Paradoxically, we’re frequently much more comfortable doing the right thing for patients who will not draw public attention.
I wish the former president continued good health. I wish the rest of us a careful review of the evidence before we burst into our doctors’ office demanding a stress test.
Did George W. Bush Really Need A Stent? (Forbes)
Former president’s stent surgery revives debate on heart care (Chicago Tribune)
President George W. Bush has stent procedure (Salon)
George W. Bush Gets Angioplasty and Stent – Was It Necessary? (The Voice in the Ear, a blog about stents)
My previous posts about angioplasty:
For Most Heart Patients Medicines are as Good as Angioplasty
Is There a Patient Educator in the House? (About a study which showed angioplasty patients did not understand the benefits of the procedure)
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
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Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
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Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
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Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.