Do You Really Know What You are Getting Into?
Consider Carefully the Risks and Benefits of Medical Procedures
The stakes are getting higher in cardiovascular and related conditions. By law, every patient who undergoes a medical treatment should have an informed consent. That means they should understand what they are getting into when they have a bypass or a stent for stable heart artery disease. They should understand the potential benefits and they should understand the risks. When big hospital systems brag about their outstanding heart programs, they are talking about procedures. They are talking about their excellent bypass surgeons and their cardiologists that put in stents. That advertising is misleading. I see nothing in their messages that helps patients understand bypasses and stents do not prevent heart attack or sudden cardiac. That is true even in patients who have stable angina (chest pain with exercise) and heart artery disease proven on heart artery catheterization. In fact, as I interact with laymen who have had a stent, it seems to me that most of them believe opening their artery saved their lives. That is true if you are in the process of having a heart attack, but if you have stable heart artery blockages and are not forming a clot, opening the artery adds nothing to optimal medical treatment.
It is optimal medical treatment (OMT) that stabilizes cholesterol deposits so that they do not rupture and cause a clot when that raw surface comes into contact with the blood. It is OMT that reduces mortality by 90% and saves $20,000 per patient per year in our country. Yet, in the United States, people who are thought to be at high risk of heart artery disease get their stress tests, caths, and procedures to open their artery very reliably. Very few organizations have made the changes to assure individuals with a high risk for heart artery disease receive optimal medical treatment (OMT) consistently. The numbers don’t lie. Most Americans don’t get OMT which involves lowering blood pressure, sugar, and cholesterol to very aggressive targets using medications and lifestyle changes that block the biology causing artery disease. Only 44% of Americans have their blood pressure controlled to the conservative target of 140/90 or less. Only 49% of Americans with proven artery disease are on a statin. Institutions who take OMT seriously control hypertension in 90% of their patients. Ninety percent of their patients are on a statin. Only about 20% of diabetic patients in this country achieve the five goals of care. The best organizations achieve those goals in 60-70% of patients. There is a huge gap between what we are doing and what we should be doing. There is too much concern about service lines and not enough interest in patient outcomes. In any other industry, these failures would not be tolerated.
Procedures to open heart arteries are not entirely benign. I don’t know about you, but my ability to think is one of the most precious things that I have. It is one of my abilities that I fear losing the most. In fact, when the point comes that I am unable to remember that I had a visit with my family, I will be ready to go. I have seen enough in my medical practice to know that there are things worse than dying. For me, losing my mental capacity is on that list. Memory loss is common after bypass surgery. 53% of patients who have had a heart artery bypass have some evidence of memory loss at the time they are released from the hospital. 24% still have some impairment at 6 months and 42% at five years. It is not surprising that these problems occur. Most patients have bypass with their heart stopped and they are on a machine to pump the blood. Of course, blood flow and oxygen supply to the brain is not as good as on an artificial pump as it is when our own heart is pumping. Low oxygen injures the brain diffusely. One of my patients was so damaged he was effectively bedridden for the rest of his life. His status was like someone with severe dementia, and it began very suddenly at the time of his bypass surgery. On the other hand, optimal medical therapy most effectively addresses vascular risk factors which are strongly associated with increased risk of memory loss.
The evidence is building by the day. Opening heart arteries should be done much less often in stable patients who are not in the process of having a heart attack. 42% is a large number of patients who have measurable memory loss 5 years after bypass. I am certain of this. If patients understood bypass does not prevent heart attack or sudden death in stable patients, but it does cause permanent memory loss in 42% of patients, there would not be as many bypass surgeries. If they understood OMT reduces mortality by 90% if they have had a heart attack, many more would get serious about OMT. If patients had a truly informed consent, they would make different choices. We cannot really claim we are providing patient-centered care until we get this right.
The blind obsession with targeting the “obstructive coronary artery disease” is absolutely mindlessly asinine. It is too little and too late. Since most heart attacks have no observable “obstructive” coronary artery diseases. Heart failure can stem from a great numbers of causes, other than just the “obstructive coronary artery disease”. This stubborn wrong headed obsession has led to tragic misdiagnosis, and major cardiac events including deaths, regardless of the “best in kind of interventions” plus “the world class medical therapies”.
Let’s be honest about all this. The “standard of care” costing the US taxpayers hundreds of billions is willfully inadequate at the best, must be revisited and fundamentally revamped/ended for the better.
We need a serious soul searching and systematic restructuring of our healthcare system!
Joseph T. Shen, MD
MCG Technology Pioneer