Wasn't it just a couple of months ago that George Bush, fit and buff at 66, led a group of Wounded Warriors one hundred kilometers across the deserts of West Texas for the Bush Institute's annual spring mountain bike ride? According to press accounts, "The former President stayed in the lead throughout the race, yelling encouragement and jokes to his fellow cyclists." Not exactly the picture of a man suffering from critical coronary artery narrowing, is it?
But suddenly, and without warning signs, he's getting a stent to prop open a blocked artery. What happened?
If it were anywhere else in the developed world-Japan, Germany, Scandinavia, England-or if he were not a "high-value" celebrity, nothing of the sort would have happened. In those countries, heart patients have similar outcomes, with far fewer operations. And extensive scientific evidence substantiates the equivalence, even superiority, of a more conservative, low-tech approach.
We know the scenario. Every year, Bush, ever the one to heed "expert advice" but not renowned as an out-of-the box thinker, dutifully reports for his annual "million dollar workup". That workup probably includes a "routine" PSA (now discouraged as a general screening test) a "routine" chest X-ray (not necessary) a "routine" EKG (also discouraged), and possibly a "routine" stress test (also discouraged in healthy individuals without heart symptoms).
Precisely the main reason NOT to have these tests is that they might just show something!
PSA's have been shown to lead to unnecessary biopsies which reveal indolent cancer that elicits life-impairing treatments that study after study show DO NOT extend life.
Stress tests may reveal glitches that lead to the next work station on the conveyor belt to a heart procedure: the angiogram (or cardiac catheterization).
In that procedure, a small catheter is threaded through an artery in the groin and into the heart, where dye is released, tracing heart function and blood flow.
The procedure is generally safe, but complications like bleeding and cardiac arrhythmias can ensue. Rarely, deaths can occur. What is sometimes overlooked by patients who undergo routine nuclear stress tests is that they get a whopping dose of radiation each time, adding to their lifetime cumulative radiation exposure which can increase the risk of cancer significantly.
Angiograms have been criticized because they equate anatomy with function. That is, a subjective call that a heart blood vessel is "blocked" logically calls for it to be opened with a small metal stent. If it works for the Rotor-Rooter man and indoor plumbing, why not for interventional cardiologists working on actual people?
You might think that no one has dared to pose the question, "Are the million plus stents we do on Americans each year really worth it?" But they did. And we've had the answer since 2007.
In 2007, the New England Journal of Medicine published the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial. I'll let the study conclusion speak for itself:
"As an initial management strategy in patients with stable coronary artery disease, PCI [stents] did not [my emphasis] reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy."
Yet the rush to unnecessary stents has continued unabated. Some blame risk-averse, liability-fearing doctors. Indeed, if patients die, at least they'll die with a "full-metal jacket" as patients with lots of stents in their coronary arteries are sometimes cynically referred to in certain medical precincts.
Others highlight the profit motive. And indeed, some "star" interventional cardiologists and some hospitals have suspiciously high rates of stent-placement. There might be a three or four-fold geographic variation in the likelihood of getting a stent depending on what state you're in. Do patients in Florida really need stents that much more than comparable patients in Minnesota? In some cases, medical audits have shown trumped up test findings leading to totally unjustified stents, and doctors have been fired or disciplined for outright avarice.
But I think something else is at work. It's just very hard, when you have technological firepower at the ready, to just stand there and "do nothing". Heroic intervention is at the heart of modern medicine. And patients demand "the best care" regardless of whether it's in their long-term interest or not.
Not that there aren't circumstances where stents are beneficial. Mostly what studies are showing is that, while survival benefits are minimal, quality of life improves for active people who have chest pain on exertion not well-controlled with standard heart meds. Additionally, most people who have heart attacks get stents because this improves circulation, and if done quickly, can limit the amount of heart muscle that is damaged.
But the above circumstances comprise perhaps the MINORITY of patients; the MAJORITY, like George Bush, get stents when they're fine and an artery appears blocked on a test.
We see countless examples of this kind of over-reach, our medical system invents elaborate "fixes" for problems that don't deserve them.
Unless we're extraordinarily disciplined, and demand better, smarter care from our doctors, this trend will continue to rage unabated, to the ruination of our economy and to the detriment of our collective well-being.
George Bush has become the latest victim of "superb" medical care. Sure he'll go on to be fine, which he probably would have anyway. But stents have a way of failing, sometimes as soon as within a year of their placement. Once the arterial wall is injured by the metal, there tends to be scarring, which results in arterial narrowing. This may necessitate repeat placement, or even prompt a more definitive "fix" with a bypass.
Suffice it to say, Bush has embarked on a long career as a heart patient, something that a high percentage of Americans over the age of 60 now undergo. There will be frequent checkups and tests, and he will be medicated to the hilt with drugs to slow his heart and thin his blood.
Psychologically, he may be undaunted, unlike many people who turn into cardiac cripples with new awareness that something is amiss in their tickers. But possibly, the combination of beta-blockers and statins that they tank him up on will put an end to his career as a post-Presidential action figure. Concern over excess bleeding while on anti-coagulants may make him think twice about careening down mountain bike paths.
Maybe you'll be luckier. Get a second opinion when confronted with the "need" to do heart tests. Consider natural alternatives like chelation (recently found to be helpful for heart patients in a 31 million dollar NIH trial) along with a low-carb Salad and Salmon Diet, and try heart-healthy supplements like fish oil, resveratrol, pycnogenol, aged garlic extract, and olive leaf.
The pity of it is that with Bush's stent another "teachable moment" in American medicine has been botched, with the wrong message reinforced for tens of millions who now think that going from the fast lane to the catheterization suite is normal and acceptable. Some ostensibly healthy folks might even be making appointments with their cardiologists to see if they, too, might be candidates for a heart "fix".
Heart patients don't just need more medicine; they need Intelligent Medicine.