The COURAGE study has caused a flutter. A perfect example of my continual assertion: American Healthcare is not about health or care: it’s about sickness and money.
Yesterday, for my radio show, I interviewed Dr. Robert Carhart, a cardiologist from University Hospital in Syracuse, NY. During the show we like to go behind the medical headlines to make sure we really understand them.
Dr. Carhart actually participated as one of the clinical investigators in the COURAGE study, and he was able to clarify many questions about the results, which showed that in non-emergency situations, drugs and medicine are just as effective as stenting for people with heart problems.
Don’t forget — I’m not a medical professional. I see things as they should be seen through a patients eyes. Well, let me tell you, my eyes were opened!
Stents came on the scene a number of years ago. They are little metal mesh sleeves that get inserted into an artery when a blockage occurs. A blockage will cause a heart attack. When someone is having the signs of heart problems, including heart attacks, a procedure called angioplasty is performed (a balloon that is inflated to clean out the artery), then a stent is installed where the blockage was to keep the artery cleaned out. Sounds like a miracle, right?
The COURAGE study weighed the use of stents against traditional medicines/drugs and found that the use of stents is no better than the use of medicine for non-emergency situations. In fact, because of the danger of problems with the stenting, which is surgical and invasive, the medicine may be a better choice.
Ohhh! But cardiologists who perform stenting procedures (called interventional cardiologists) make plenty of money when they perform an angioplasty and insert stents! They don’t make money from the drugs that can be prescribed instead. They are NOT happy with this study!
(And by the way — neither are the companies that manufacture the stents, all of which saw their stock prices drop big time this week.)
Another problem, according to Dr. Carhart, is that patients who have just had a heart attack get a stent put in as part of the blockage repair, and then, the interventional cardiologist will tell them, “Gee Mr. Patient, we noticed you have two more blockages. As long as you’re here, why don’t we stent them, too?” The patient says, “Sure, you might as well,” then goes on his merry way thinking he’s been protected — and he may not be.
And the interventional cardiologist just tripled his income from the procedure — to no real benefit to the patient. Such a deal (for the doctor, of course)!
While the stenting for the blockage that caused the heart attack may definitely be a life saver, additional stents may not help much. In fact, according to Dr. Carhart, too many patients think the additional stents will absolve them of any responsibility for compliance with other important aspects of heart health such as diet, exercise and drugs. Those patients think the additional stents will protect them — and they don’t.
Here’s the bottom line: if you are NOT in an emergency situation (no impending or immediate heart attack) and you are offered stenting, talk to a cardiologist who understands the COURAGE study and then research the benefits of medicine vs stenting for yourself. To the best of your ability, make sure the doctor who advises you is giving you a balanced recommendation — meaning — he isn’t profiting from whatever he is recommending to you.
If you are in an emergency situation — by all means — if the stenting is recommended, it may be a real life saver to you, so consider it seriously. BUT — additional stents? They won’t necessarily be the right choice for you. If you are someone who knows you are at risk for a heart attack, you may want to consult with your cardiologist sooner, rather than later, about the right choices for you.
Yup — it’s that “think like a consumer” thing again. Your health and pocketbook will both benefit.
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As a nurse in critical care I have also seen patients who received a row of stents when they needed open heart surgery returning time & again with blocked stents or other areas blocked off. (Smokers & Diabetics beware this is you)
This is not in their best interest, it gets them out the door, but turns them into a time bomb who has to take a very expensive drug that isn’t always effective to prevent restenosis.
I have watched the extension of many a patient’s death through a combination of unrealistic expectations of families & physicians who won’t tell them what is going on in words they can understand.
Points well made, Claudia. Too often patients leap to conclusions about their outcomes that aren’t true, because the doctors don’t manage their expectations well enough.
That means the interventional cardiologists are profiting and shortening life at the same time. Makes me wonder what happened to, ‘first, do no harm.” ?
Trisha,
I just read your guest editorial on stents. It was interesting to me in that I had just been reading a blog post on the inevitable decline these procedures will suffer as better information gets out on the Heart Scan Blog http://heartscanblog.blogspot.com/. Dr Davis is a cardiologist who treats most of his patients with a combination of high tech scans and blood testing combined with diet and selected supplements. He has much better long term results than his fellow doctors who stick to traditional (and more profitable) procedures. His data about vitamin D status and heart health really needs to get out to the public. It will be interesting to see how all of this plays out in the next few years.
[...] separately, a couple of links have arrived in my mailbox to news stories that follow up on the stent vs. medicine study I wrote about a couple of days ago. One article regards the reactions on the parts of insurance companies who will now re-examine [...]
This subject is more complex that the rather simplified summary above. I work with interventional cardiologists in the hospital daily - and they don’t triple their income by putting in 3 stents. If you put 2 stents in the same artery, you get paid the same as if you put in one. These men and women break their back hunched over paitents while wrapped in lead protective clothing and get exposed to lots of radiation. It’s not all big buck - contrary to the opinions you were provided with… The COURAGE study actually showed stenting to be more effective for many patients who did not get adequate relief from medical therapy. There are a lot of people who benefit from stenting in the non-emergency setting.
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