Bush's unnecessary stent--but wait folks, there's more!

By Dr. Hoffman

Many of you have commented favorably on my recent newsletter article "Former President GW Bush Gets Stampeded Into Undergoing a Stent Operation." http://www.drhoffman.com/page.cfm/1216.

Mostly, amid the torpor of late August, people are too busy squeezing out the last full measure of summer to care much. And that's unfortunate because we're missing a big teachable moment that goes to the heart (excuse the pun) of what's wrong with our health care system. Press coverage of the event has ranged from bland and uninformed to decisive and sophisticated.

An example of the former is an article in the Palm Beach Post entitled "What You Can Learn from Bush" http://www.palmbeachpost.com/news/lifestyles/what-you-can-learn-from-bush/nZJ8j/

(Hear my commentary on the article in my recent Intelligent Medicine podcast http://www.drhoffman.com/podcasts/channel-1/drhoffman-com-2013-08-13-54.mp3 )

The Post article perpetuates the myth that no matter what you do, heart disease can still creep up on you. While health is not always a merit system, and bad things do happen to good people, this medical fatalism perpetuates indiscriminate statin use in healthy seniors, and routine physical exams that land vigorous symptom-free Boomers in the angioplasty suite.

"[Bush's] condition should serve as a stark reminder than none of us - no matter how healthy we think we are - is immune from heart disease," writes health correspondent Steven Dorfman.

The message is: "Be afraid." Underlying this proposition is perpetuation of dependency on the medical system not just to heal us when we get sick, but also to tell us if we're at risk, and to undertake dubious high-tech fixes to stave off hypothetical diseases. By over-diagnosing us with pre-conditions, the medical-industrial-governmental complex abrogates our autonomy and extends its control over hordes of well people. A medical crisis is self-limited in duration, but a vague risk can keep a patient profitably on meds for decades. Or prompt a surgical "fix".

The Palm Beach Post article gets it precisely WRONG when it states that Bush needed a stent because he had a blocked artery. The 2007 COURAGE study disproved that, showing that, even in patients with mild chest pain well controlled with medication, stents offered NO advantage in terms of reducing risk of dying or even staving off subsequent heart attacks.

But Dorfman piously intones the orthodoxy: "Which brings us to the other lesson from Bush?s episode that all baby boomers would be well-advised to heed: Don't skip your routine annual physical exam. Your life just might depend on it."

Unfortunately, Bush was a victim of his own celebrity and the gold-plated annual physical to which high-profile individuals are entitled. A "routine" EKG (which medical authorities now discourage in healthy asymptomatic individuals like the ex-Pres) led to a "routine" stress test, which prompted an angiogram, "just in case". While in there, the cardiologists couldn't resist the impulse to "fix" a narrowed artery with a tiny metal mesh device.

In the New York Times article, which is a lot more incisive ("Heart Stents Still Overused, Experts Say" http://well.blogs.nytimes.com/2013/08/15/heart-stents-continue-to-be-overused/?ref=health&_r=1 reference is made to the "oculostenotic reflex". This is a tongue-in-cheek term invented by doctors referring to the tendency of cardiologists to eyeball an angiogram, make a subjective judgment call that an artery is "blocked", and reflexively implant a stent.

An example of which is the case of Baltimore cardiologist Mark Midei, who had his license revoked for doing unnecessary stenting. According to the Maryland Board of Physicians, Dr. Midei had a nasty habit of exaggerating angiogram findings to justify performing stents. Small deposits of plaque were upgraded to "80% blockage" to capture generous reimbursements for stent placement.

So prolific was Dr. Midei that he was once feted by Abbott Labs, a prominent stent manufacturer, for achieving the unique milestone of implanting 30 stents in one day. For this distinction, Abbot spent $2159 to buy him a whole slow-roast pig for a barbecue party at Midei's home.

It is now estimated that Midei performed 585 stents that were "medically unnecessary" between 2007 and 2009. At about $30,000 a pop, Medicare reimbursed $3.8 million of the $6.6 million billed for those procedures.

The Times article echoes what I said in last week's newsletter article:

"In an emergency, when someone is having a heart attack, the operation can be lifesaving. But far too often, studies show, stents continue to be implanted in patients who stand to gain little if any benefit. Last month, two of the country's largest medical organizations identified the procedure commonly used to place a stent - called a percutaneous coronary intervention, or angioplasty - as one of five highly overused medical interventions."

The Times is beginning to get it. The article cites Dr. Michael B. Rothberg, the vice chair for research in the medicine institute at the Cleveland Clinic. He points to "two of the leading myths about coronary artery disease."

"One is that dietary fat creates plaque and clogs arteries. In fact, studies show that diets that include fats like the monounsaturated and polyunsaturated kinds found in nuts and olive oil can protect against heart disease. The other widespread misconception about coronary artery disease, Dr. Rothberg said, is that narrowed arteries are the problem."

Wow. You heard it here first. Maybe the Times is finally beginning to get it.

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