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The New Science of Vascular Disease

BesterrmannVascular
disease and the conditions that produce arterial problems consume
roughly one- third to one-half of the $2 trillion annual spend in
American health care. The science and systems exist today to dramatically improve the quality and cost related to cardio-metabolic
conditions but almost nothing has been done to implement these new
tools since the Institute of Medicine (IOM) published “Crossing
the Quality Chasm
” in 2001.

The most glaring
example of the failure of medical and political leadership in these
matters can be found in the treatment of chronic conditions, which
consume 70 percent of our health care dollars. “Crossing the
Quality Chasm” was a stinging indictment of American medicine,
describing a system that is in need of fundamental change, with many
professionals and patients concerned that the care delivered is not
the care that we need. The report described a system that harms too
frequently and routinely fails to deliver its potential benefits.

It went on to say
that we should be able to count on care that is based on the best
scientific knowledge, but that there is strong evidence that this is
frequently not the case. It takes 17 years for new scientific
evidence to be widely implemented and even then there is excessive
variation. The report said “current care systems cannot do the
job, Trying harder will not work. Changing systems of care will.”

Hard business,
but make no mistake. Half measures will not work here. Improvement
will require a thorough re-engineering of the way we care for chronic
conditions. The way we handle cardio-metabolic disease offers the
most striking example of how this indictment is justified.

Virtually every new
patient we see at Holston Medical Group in our chronic disease clinic
understands artery disease to be a plumbing problem. And little
wonder. A billboard in town sponsored by a local hospital recently
proclaimed “more procedures equal better outcomes” in heart
disease. So naturally, the public understands coronary artery disease
to be like scale in a pipe, a progressive blockage.

The current system
of cardiac care works like this: If a patient has a 60% blockage of
an artery, it does not interfere with blood flow. It does not cause
chest pain. The patient is thought to be safe, and nothing much is
done for or to the patient.

If the blockage is
70% or greater, it begins to interfere with blood flow, it may cause
pain, the patient is thought to be in danger, and this level of
disease activates our entire system of stress tests, cardiac
catheterizations, stents and bypasses. 100% blockage is a heart
attack and if we catch the blockage before it becomes 100% and open
it with a bypass or a stent, then we have made the patient safer. We
have saved him from a heart attack. This is the way most patients and
clinicians currently understand the problem of coronary artery
disease and it is the way our system operates.

The plumbing model
of coronary artery disease has been thoroughly discredited in stable
patients, beginning with the landmark work of WC
Little and others
summarized by Erling
Falk
,
PK Shah, and Valentin Fuster

in Circulation in 1995
. This article reviewed 4 investigations
that compared the results of two heart catheterizations done in the
same patient. The first catheterization had shown a blockage
(stenosis). Some of these patients went on to have a heart attack,
and then a second heart catheterization was done at the time of the
heart attack.

The results of the
second catheterization were shocking. The original blockage was
there, but it had not caused the heart attack. The myocardial
infarction was caused by complete blockage of the artery by clot,
frequently in a different place and surprisingly often in a totally
different artery. In the studies summarized by Falk, only 14% of
heart attacks occurred in an artery which had shown a 70% or greater
stenosis on the first catheterization. Since it generally takes a 70%
blockage to produce angina, this explains the reason that most heart
attacks occur as the first cardiac symptom. The patients did not have
enough vascular obstruction to cause chest pain beforehand.

The WC Little
article was published in 1988, 21 years ago. Dr. Little did a very
good job of describing the new vascular paradigm in this pioneering
work in the discussion at the end of the article:

Because it was difficult to predict the site of the subsequent
occlusion in our patients from the initial coronary angiogram,
coronary bypass surgery or angioplasty appropriately directed only at
the angiographically significant lesions initially present in almost
all of our patients would not have been effective in preventing the
majority of myocardial infarctions. This does not indicate that
arteries that do not have obstructive lesions should be bypassed or
dilated. Instead, effective therapy to prevent myocardial infarction
may need to be directed at the entire arterial tree, not just at
obstructive lesions. Such therapy to prevent myocardial infarction
might rationally include avoiding smoking, reducing serum
cholesterol, administering agents that alter platelet function such
as aspirin, or possibly fish oil, and pharmacologic agent to prevent
spasm of the coronary arteries.

These early landmark articles have informed the work of leading
authorities in cardiology.

So how does a heart
attack happen? LDL-cholesterol (or bad cholesterol) plaques build up
in the wall of the arteries. They do not belong there and the body
attacks these plaques with white blood cells (pus cells). These
plaques become highly inflamed collections of LDL cholesterol and
pus. They function like little boils or abscesses and they rupture.

When the contents
come in contact with the blood within the vessel, it causes the blood
to clot. This is why aspirin, an anti-coagulant, prevents heart
attack. It is why tissue plasmin activator, a clot buster, will stop
a heart attack in progress by breaking up the clot and restoring flow
to the artery.

The fundamental,
underlying event in myocardial infarction is plaque rupture. Coronary
artery calcium is a reflection of healed plaque rupture. In early
disease, multiple discrete dots of calcium can be seen. The more you
have, the higher your risk. A test called a calcium score assigns you
a risk level based on how much plaque you have.

The Tim Russert
story is an unfortunate reflection of how these dynamics play out in
our system. Ten years before he died, Mr. Russert had a calcium score
of 200, which roughly translates to 40 plaque ruptures. A few months
before his heart attack, his stress test was normal, probably
indicating a low risk from obstruction. On autopsy, one of the
arteries was completely blocked by clot. The Russert example fits the
new paradigm perfectly.

Our system does too
little too late. In cardiovascular disease, the care model is built
around opening blockages in patients with late disease, which
relieves symptoms, but does not prevent heart attack.

Leading experts now
agree that preventing heart attack requires identifying patients at
high risk and then stabilizing plaques by aggressively treating blood
pressure, high cholesterol, triglycerides and glucose with diet,
exercise and evidence-based medical treatments.

Remember,
investigators laid this out in 1995 based on studies going back to
1988. We are now at 20 years and counting. We have passed the 17 year
mark, and most patients still don’t get the care they need.

The
science of vascular disease has changed dramatically, though the
evidence shows that aggressive application of this science makes a
real difference. The
COURAGE trial’s
purpose was to prove that, when added to “optimal
medical treatment” – that is, an optimal drug reigmen – stents
further protected the patient. Patients with stable angina and
blockages greater than 70% received optimal medical treatment for
blood pressure, cholesterol and diabetes. Then the patients were
randomly assigned to receive the appropriate stents or no stents. At
the end of 5 years, there was no difference in the number of cardiac
deaths and heart attacks. Even more interesting, 70 percent of
patients who did not receive stents experienced complete relief of
their pain, most in the first year.

The
Courage Trial confirmed the findings of a great deal of research that
addressed the same issue. An article in last year’s Journal of
Managed Care summarized 13 studies since 1993 that compared optimal
medical treatment alone and combined with stents. In stable angina
patients, there was no benefit of angioplasty with stenting over
optimal medical therapy alone. The authors thought the findings of
their analysis might “
engender
additional support for a policy cognizant of the lack of marginal
benefit of PCI (stents) over that of MT (medical therapy) alone in
nonacute cases
.”

Everything
bad that happens to an adult onset diabetic is vascular. At
diagnosis, the type 2 diabetic has an 80% lifetime risk of heart
attack and stroke. Again, we do too little too late. Guidelines
emphasize checking for the late consequences of diabetes and vascular
obstruction: doing eye exams for retinopathy; foot exams for ulcer,
nerve damage and poor arterial supply; doing special tests looking
for arterial blockage in the leg.

In
the
Steno 2 study
, 160 type 2 diabetes patients were divided into 2
groups: optimal medical treatment (where the emphasis was on
controlling risk factors) versus usual care. At the end of 7 years,
there was a substantial difference between the two groups in terms of
diabetic complications and everyone was moved to aggressive care for
the next 6 years.

Nonetheless,
there were major differences in outcomes. In the usual care group, 40
out of 80 people were dead vs. 24 out of 80 in the aggressive care
group. The usual care group experienced twice as many cardiovascular
deaths, 4 times as many heart attacks, 5 times as many strokes, 11
times as many stents, over 3 times as many amputations, and 6 times
as many people were placed on dialysis. The usual care group averaged
2 vascular catastrophes each over a 13 year period.

We
need to divert resources from an ineffective system of dealing with
the late complications of diabetes and focus on producing the optimal
medical therapy that will keep those problems from happening in the
first place.

In the face of this irrefutable new science, some stent advocates and
other naysayers have said, “that is all very well, but optimal
medical therapy does not exist, and so these studies do not apply to
the real world.” They are wrong. Thousands of diabetics in Holston
Medical Group have risk factor control rates that are very close to
those achieved in Steno 2 and Courage. We and others have “Crossed
the Quality Chasm” in cardiometabolic conditions and are continuing
to improves.

The solutions are at once terribly complex and very simple. Systems
produce the results they are designed for. We need to rework our
cardio-metabolic care system. Because that system produces what it
pays for, we need to start paying for treatments that actually
produce the results intended. In this case we need to pay a premium
for optimal medical treatment as an initial strategy in high risk
patients and in patients with stable vascular disease, with a
priority placed on proven, evidence-based treatments.

We
need to stop paying for stents and bypasses in stable angina patients
until they receive a trial of optimal medical therapy. Until we do
that good people will continue to die and suffer needlessly. We are
putting our own friends and family at risk. We have robbed Tim
Russert’s grandchildren of the opportunity to know their remarkable
grandfather.

William
Bestermann MD
is
a Preventive Cardiologist and Medical Director for Integrative
Services at the Holston Medical Group in Kingsport, TN.

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9 replies »

  1. We have known for years that we have a multi trillion dollar “health care system” that treats diseases, 80% of which are preventable by simple lifestyle changes. The work of Dr. Colin Campbell (China Study) demonstrates beyond reasonable doubt that adopting a plant based diet, avoiding terminally stupid behaviors like smoking and drug/alcohol abuse, getting moderate daily exercise and avoiding sugar/fat/salt rich junk food America could save thousands of billions of dollars each year.

  2. Thank you for this article. I did a lot of work with modern medicine in my history of American Medicine class and I find it very difficult to believe the way we came to our current affairs in such a short time. A lot has changed from the early 1900’s when doctors hardly had an ounce of respect.

  3. Dr. Bestermann’s article is a reminder of how we can be so close to a solution of a problem that we cannot see it.
    The truths in his article relate not so much to the economics so of healthcare delivery (ie ‘profit-motive’) but more to the disparity of knowledge among doctors ( ignorance of best practices) and an unorganized, diffuse array of healthcare providers who practice unrestrained without guidance or oversight.
    We know the medical care truths that Dr. Bestermann recites, why are they not implemented?
    We talk too much about the economics of healthcare delivery forgetting that the excessive costs are really the malignant products of unregulated care and unorganized practices.
    We think that there is an equally educated and equally knowledgeable pool of ‘doctors’ who provide equally good healthcare.
    It ain’t so.
    Most of what Dr. Bestermann is discussing is attributable to the poor care of diabetes.
    We have standards of care for the treatment of diabetes that if only universally implemeted would diminish the horrendous vascular, and other, complications of this multi-system disease.
    Trouble is we have more ways of delivering game apps to the i-phone than we have to deliver these established practices to the mutltitudes who treat diabetes according to their own personal nuances.
    There is no organized body of medicine. Everybody is a doctor today. It is a free-for-all.
    Diabetes ‘care’ is delivered by M.D.s with varying knowledge bases, D.O. (do bones cause diabetes?), P.A., A.R.N.Ps-no one is watching these ‘practice’, Family Medicine Chiropractors who treat diabetes, CDEs, and a gazillion others all doing different things. This is bad.
    We may be getting a broadband super-highway, which is good, but, will it be the internet highway to nowhere?
    I vote for, as I said in a previous posting, to take the words off of the pages of the ADA’s and ACCE’s Standards of Care for diabetes and develop a set of core care behaviors that can easily be followed and must be followed for reimbursement of diabetes care. Place these in a functional format that guides treatment ans monitors risk accumulation and make this program available to certified diabetes practitioners.
    Such a unified template of diabetes care will corral in the vague, disparate, every ‘doc’ for himself method of treating the most serious, expensive, and treatable social and medical disease we have.
    Let us use the medical superhighway to structure how care is to be delivered and pipe it in rather than staying up at night figuring how to pay less for the poor excuse for care that we now deliver in this country.
    Louis Siegel, M.D.
    (No conliciting commercial arrangements to report except I have written and used such a program on my patients.)

  4. Studies looking at who gets into medical reveal that it is those who get into medical school are highly likely to be suburban, white, upper socioeconomic class. Search for Bob Bowmans work on the internet, and you will see why there are few rural doctors and clusters of specialists. I don’t think it is a business mindset totally, some of it is my father was a cardiologist and made this level of income, so I should to.
    Great work showing how culture influences decisions, as does payment.

  5. Great piece, Bill. Thanks for reminding us again that myocardial infarctions stem from a metabolic problem, not a plumbing problem, and that deaths from hypertension, diabetes, and dysplipidemias are almost always vascular in nature and due to a ruptured plaque. Our epidemic of vascular deaths are also cultural in nature. A book called Medicine and Culture by Lynn Payor, a journalist who had lived in multiple countries, noted that Americans think of the body as a machine. If the face drops, lift it, if the pipes plug, unclog them, it the joints creak, replace them, and so forth. Thanks, Bill, for straightening out our thinking with our metabolic paradigm.

  6. Absolutely excellent piece which explains a complex subject in relatively simple terms. I don’t understand why more cardiologists don’t “get” it. It does tend to make one suspicious of their motives.

  7. Wonderful piece, Bill. Many thanks for laying this out so clearly and concisely for others, myself included, to use in helping convince our nation’s leader that good quality care is also lower cost care.
    Regards, DCK

  8. Good stuff here.
    One fundamental question driving this issue centers around the role of the physician: Is s/he working for the money or the patients? Obviously this is a false dichotomy for most of our physicians. However, in my discussions with medical students, it seems the current system tailors its recruitment process to the business mindset. There’s a lot of money to be made in performing a CABG. Hospitals, cardiologists, and those looking at possible careers know this. Have there been any studies as to the type of person that is being recruited to medical school across time? I know the primary reason I decided not to go into medicine was that the physician I wanted to be doesn’t exist anymore.
    The fiscal incentives must be changed first and foremost. That will reward healthy physician practices and eventually alter the type of physicians recruited into the system…

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