Paying Twice as Much for Double the Chance of Dying

In the last post, I wrote about the massive contribution made by Dr. Bernard Lown to the topic of coronary artery disease. The Lown institute pointed to another study on stable heart artery disease that puts the final nail in the coffin. Now, the only reason to put stents in patients with stable coronary artery disease is symptoms that persist despite best practice medical treatment or optimal medical therapy.

This is another example of a medical treatment that makes sense, but does not work. It makes sense that severe multiple heart artery blockages that reduce the blood supply to the heart, would not provide the fuel and oxygen needed for proper heart function. So patients with poor heart pumping function and multiple heart artery blockages are a group with stable heart artery disease where stents were still recommended.

In 2022, there was another study of opening arteries in patients with stable heart artery disease. Here is a brief analysis of that study from the Lown Institute: “REVIVE gives stents “best chance to win” but still fails

The REVIVE trial enrolled 700 patients with conditions thought to be most helped by stents: those with a severe coronary (heart artery) disease and left ventricle dysfunction (heart failure), but also viable (live) heart muscle. They randomized patients to optimal medical therapy (best practice medical treatment) or medical therapy plus PCI (a stent).

The results showed no difference in the rates of the primary outcome (death or heart failure hospitalization) between the two groups after 3.5 years. There was also no difference in heart function or patient-reported quality of life. No subgroups saw an additional benefit from PCI (stent).

The REVIVE results were shocking to many cardiologists. Dr. Sanjay Kaul said, “This was the best chance for PCI to win (they really cued it up for PCI), and it still came up short.”

Let’s look into the REVIVE study a little deeper. Here is the design copied directly from the text in the New England Journal of Medicine. “We randomly assigned patients with a left ventricular ejection fraction of 35% (severe heart failure due to poor pumping function) or less, extensive coronary artery (heart artery) disease amenable to PCI (a stent), and demonstrable myocardial viability (live heart muscle) to a strategy of either PCI plus optimal medical therapy (PCI group) or optimal medical therapy alone (optimal-medical-therapy group). The primary composite outcome was death from any cause or hospitalization for heart failure.”

Here are the results: “ A total of 700 patients underwent randomization — 347 were assigned to the PCI group and 353 to the optimal-medical-therapy group. Over a median of 41 months, a primary-outcome event occurred in 129 patients (37.2%) in the PCI group and in 134 patients (38.0%) in the optimal-medical-therapy group.” It is true. This is a very high-risk group. Over three and a half year about a third of them died or were hospitalized for heart failure. Most importantly though, adding a stent to optimal medical therapy did NOT make a statistically significant difference.

This is a great example of the difference between our healthcare system and the healthcare system in other developed countries like the United Kingdom. They have a 26 page guideline on stable heart artery disease that was written in 2011 aimed at primary care clinicians. The similar guideline from the American Heart Association is 118 pages, it is aimed at cardiologists, and it is essentially useless for primary care clinicians.

Here is the guidance from the UK on stable heart artery disease:

“Offer people optimal drug treatment for the initial management of stable angina. Optimal drug treatment consists of one or two anti-anginal drugs as necessary plus drugs for secondary prevention of cardiovascular disease.

Consider revascularisation (coronary artery bypass graft [CABG] or percutaneous coronary intervention [PCI]) for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment.”

Opening arteries is much more expensive than optimal medical treatment. Our system is focused on opening arteries and most Americans have no access to optimal medical treatment. Allowing special interests to control our healthcare system and providing expensive treatments that don’t help while not providing inexpensive treatments that do help is the reason twice as many American die of heart artery disease and pay twice as much for the privilege. When we do implement optimal medical treatment for cardiovascular disease in this country the results are spectacular. You are ten times as likely to be alive in five years with huge savings in cost. You should demand change that serves the people and drains the swamp.