Writing in the New Yorker this week, cardiologist Lisa Rosenbaum examined the debate over the necessity of stenting procedures, noting that hard-and-fast rules governing appropriate use of the treatment are not easily applied to real-life patients suffering from chronic heart disease.
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While the benefits of stenting to open blocked arteries and restore blood flow in heart attack patients are well known, the value of the procedure for stable patients with chronic heart disease, when blockages build up over time, is less certain. Several studies have found that when it comes to treating chronic disease, medications—including statins, aspirin, and beta blockers—are as effective as stents.
Regardless, many clinicians continue to use stents for patients with chronic heart disease, sparking widespread concerns about its overuse. In August, two leading medical societies named stents as one of the five most overused procedures in medicine. At the same time, a handful of widely publicized scandals—including a Maryland cardiologist who allegedly performed unnecessary stenting procedures on hundreds of patients—has fueled a national debate about the nation's "epidemic" of medical waste.
Real life doesn't resemble clinical trials
Although "super-star" studies, including the landmark COURAGE trial, have suggested that drugs are as good as stents for the treatment of stable coronary artery disease, Rosenbaum argues that it would be a "colossal oversimplification" to extrapolate those findings to everyday clinical practice.
She notes that clinical trials often exclude patients who have high-risk characteristics—or nine out of 10 of otherwise eligible patients. Moreover, clinical trials are equipped with enough resources and staff to ensure that patients are taking their medications and adjust dosages. In reality, medication adherence is only about 50%, Rosenbaum writes.
And while it's difficult to apply clinical findings to the treatment of a particular patient, it's harder still to use the data to create broader guidelines for the treatment of any cardiovascular patient. When a group of expert cardiologists were asked to create blanket guidelines, they realized that there are many individual factors to consider in addition to medication, including acuity of the disease, the patient's degree of chest pain, the results of stress tests, and which of four main arteries are blocked.
The trouble with measuring 'appropriate' stent utilization
Separately, Rosenbaum highlights a study that examined the appropriateness of over half a million stent procedures performed in the United States. The study found that in the 70% of patients who received stents while having a heart attack, 99% of the stents were appropriate; however, among 30% of patients with heart disease, only 50% of stents were deemed appropriate.
The findings do not mean that half the stents placed in heart disease patients were inappropriate: 38% of stents placed in those patients were deemed "uncertain," meaning doctors were unsure whether or not the stent would be beneficial.
Overall, only 3.5% of the half million stents placed in the United States over the study period were found to be inappropriate, Rosenbaum writes.
- Is your cardiovascular program able to demonstrate that it's delivering high-value, appropriate care? The Cardiovascular Roundtable offers four steps to better track utilization and respond to scrutiny.
Meanwhile, Rosenbaum notes that some patients with stable disease might opt to receive a stent when there is no evidence that it will prolong their lives because it makes them feel better. For example, an NEJM analysis of the COURAGE study found that patients who received stents reported less chest pain and better quality of life in in the first two to three of follow-up visits.
"In this era of shared decision-making, when we are urged to ask our patients what they want, which do you think they choose when you tell them that a stent won't necessarily make them live longer but might make them feel better?" Rosenbaum asks.
In short, Rosenbaum concludes, unnecessary care is not "simply the consequence of profit-driven doctors"—a simplistic view does not account for the "tremendous uncertainty upon which most of medicine is practiced" (Rosenbaum, New Yorker, 10/23).