If You Are a Hammer, Everything's a Nail

More on my heroes at Harvard

In my last post, I wrote about my heroes at Harvard— Dr. Peter Libby and Dr. Bernard Lown. I have written for four years in this space about the power of best practice medical treatment or optimal medical therapy (OMT) to prevent heart attack and sudden death. Dr. Lown was a real pioneer on the subject. His Lown Institute continues to sound the alarm about the overuse of cardiology procedures.

“In 2020, hospitals placed more than 45,000 coronary (heart artery) stents in Medicare patients that met criteria for overuse, a recent report from the Lown Institute Hospitals Index finds. Coronary stents were the most overused service by volume of the eight measured, and were provided unnecessarily even at some of the most prestigious hospitals in the country.” The rates of stent overuse varied widely. At some hospitals nearly 50% of stents were inappropriate. In others, the rate was as low as 5%. An article in Forbes says that American taxpayers spent 800 million dollars a year on inappropriate stents in Medicare patients. That is a huge amount of wasted money. Even more importantly, these patients received an invasive treatment with significant risks that provided them with no benefit. Two women close to me lost their husbands due to bypass surgery. One died on the table. Another died of uncontrollable infection after the surgery. That is an awful result of a procedure that was not needed.

Here is a quote from a talk that Dr Lown gave in 2012. “Justification for revascularization is based on claims of increased survival, reduced toll of myocardial infarction and improved quality of life. By the late 1960’s, I learned that in a majority of patients, coronary heart disease was largely stable, and did not demand a rush for or even need for revascularization.

“I was persuaded that investigating this problem would be difficult once patients were hospitalized. As a result, I founded The Lown Clinic. Almost immediately, we launched a study. We intended to randomize post-angiography (post heart catheterization dye test) patients to either revascularization (opening arteries) or medical therapy. The study aborted before it began. After patients were informed by interventionists (cardiologists who do heart caths and stents) and house staff of their coronary anatomy, coached in the lurid prose then and now in use, every patient opted for coronary artery bypass grafting (CABG).

“Coronary angiography (heart artery dye test) was a funnel for interventions. Its purpose was largely to guide the operator to the narrowed vessel. To diminish coronary procedures required bypassing coronary angiography. We decided to study patients with multi-vessel disease over a long time frame without resort to angiography.

“During the ensuing 35 years, we published four studies in high-profile medical journals involving about 1,000 patients. Outcome data were remarkably consistent. Cardiac events were extraordinarily low, about 1.0 percent annual mortality rates. Our referral for revascularization increased from 1.1 percent annually during the CABG (bypass surgery) era to around 5 percent during the stenting era. Since a majority were second opinion patients, nearly all would have been revascularized.

“Let me repeat. Over any five-year period, we referred less than 30 percent of patients with multi-vessel coronary disease for revascularization. Those would mostly be patients with severe blockages who had continued intolerable symptoms despite best practice medical treatment.

Dr. Lown was a leading cardiologist at Harvard. By the late 1960s, he had concluded that best practice medical treatment or optimal medical therapy was as good as invasively opening arteries in stable patients. He started treating patients that way over 50 years ago and his results were outstanding. During that 50 years, a mountain of evidence has confirmed that adding a stent to best practice medical treatment in a patient with stable heart artery disease does nothing to prevent a heart attack or sudden death. Here is the key quote:

“We intended to randomize post-angiography patients to either revascularization or medical therapy. The study aborted before it began. After patients were informed by interventionists and house staff of their coronary anatomy, coached in the lurid prose then and now in use, every patient opted for coronary artery bypass grafting (CABG).”

Once the patient has a heart catheterization and the cardiologist shows her the blockage in the artery and says that opening the artery can save her life, she will always choose a bypass or a stent. It will not save her life, and the information is often incorrect, but the message is clear. If you refer a patient with stable heart artery disease to a cardiologist and they have a cathterization, they will have a procedure to open their artery even though the procedure exposes them to risk, is very expensive, and provides no additional benefit. Even more disturbing is the fact that they don’t get best practice medical treatment provided by a team using a protocol. The power of optimal medical therapy is even greater than it was 50 years ago which makes current practice even more indefensible.

The Lown Institute does not just write about inappropriate use of stents. They rank every hospital in the country on the value and appropriateness of their care. You can look at many aspects of your hospital system and see how they rank on this link which can serve as a valuable resource for you. All care is not the same. All care is not appropriate. Be sure you get what you need.

Many cardiologists are like hammers. They see every patient with heart artery disease as a nail who needs a heart artery catheterization and then a heart artery stent if a blockage 70% or greater is found. This is one of the deepest darkest corners of the medical swamp. Many Americans believe their institutions don’t serve them. That is certainly the case for Americal medicine. The phrase "drain the swamp" is commonly used to describe efforts to remove corruption, special interests, and lobbying from a political system. The AMA, American Hospital Association, the American College of Cardiology and your massive local hospital system are all special interests that are actively engaged in lobbying to keep the current game in play. You can’t drain the swamp by firing some little old lady in the government. You can drain the swamp by developing primary care teams in your community that go straight to best practice medical treatment if you have stable heart artery disease. The entire country of England does that and they live longer for half the money. Draining the swamp successfully requires identifying root causes and addressing them effectively. The wealthy and powerful distract you from the real problem by attacking Harvard and firing little old ladies. Don’t fall for it!!!