Despite Compelling Evidence Proving Heart Artery Stents Do Not Prevent Death or Heart Attack in Stable Patients, Their Use Has Declined Very Little Since 2010
Perverse Financial Incentives are To Blame
Despite compelling evidence proving heart artery stents do not prevent death or heart attack in stable patients, their use has declined very little since 2010. This is critical new information just published in the Journal of the American Medical Association. We have known since 1995 that heart attacks do not occur because of chronic blockages that get worse and close off. Instead, heart attacks happen because cholesterol deposits form little pimples that break open and start the clotting process which blocks the artery and cuts off the blood supply to the artery downstream. Optimal medical treatment stabilizes those deposits, so they do not cause a clot and dramatically reduces the risk of heart attack. Compared with usual care—where patients reliably get unnecessary stents, but they do not receive optimal medical treatment (OMT)— individuals with a high risk of heart attack who get OMT have one fourth as many heart attacks, their mortality is reduced by 90%, and the annual savings per patient are $21,900.
The evidence that elective stents in stable patients add nothing but increased cost and risk to patients on OMT is irrefutable. The landmark Courage trial published in the New England Journal of Medicine was among the first to prove this critical point. Within a year, 70% of these patients in this study had complete relief from their chest pain from medical treatment alone. For these patients, stents add nothing. In the last 15 years, there have been 15 clinical trials that prove optimal medical treatment alone is as good as optimal medical treatment plus a stent. The Orbita trial proved a stent does not increase exercise duration before angina develops any better than OMT. The equally important Ischemia Trial proved OMT alone is as good as OMT plus a stent even in patients with moderate and severe heart artery disease. All this information has been published in the best medical journals in the world. Taken together, these studies prove OMT alone is as good as OMT plus a stent in virtually all stable patients with coronary artery disease. OMT should be a universal standard of care in high risk patients.
Stents in stable patients are done electively-they are scheduled procedures. A mountain of research proves they have no value, but practice has changed very little. After the landmark COURAGE trial in 2008, elective stents in stable patients declined 24% between 2010 and 2013. Since then, they have increased by 2%. Does that mean that only one fourth of interventional cardiologists can interpret this evidence to provide patient-centered care? No. Let me be blunt. It means the hardest lesson a human being can learn is one that reduces his or her income. Stents in stable patients have not decreased because of perverse financial incentives. Stents and hospitalizations generate a lot more money than OMT which only requires primary care office visits and proven generic drugs.
This reflects a broader problem in American medicine that we have known about for two decades but have still done almost nothing about. Thousands of Americans are suffering, dying, and enduring severe financial hardship because we have not translated this science. It is part of the reason Europeans live longer for half the cost. Citizens of Singapore live longer for one fourth the cost. This failure impacts the people who pay our medical bills at every level-governments, employers, and families. We are all participants in the same medical system. The executives who are not leading the turn from opening arteries to OMT are putting themselves, their friends, and their families at risk. This information is especially important for leaders in companies that are self-insured for healthcare. If you are looking for value in your medical care, OMT is the low-hanging fruit. If you find this information helpful, please subscribe. This site trains health leaders and providers to produce OMT.