Earlier this month, the editors of THCB saw fit to post my essay, “The End of the Era of Coronary Angioplasty.”
The comments posted on THCB in response to the essay, and those the editors and I have directly received, have been most gratifying. The essay is an exercise in informing medical decisions, which is my creed as a clinician and perspective as a clinical investigator.
I use the recent British federal guideline document as my object lesson. This Guideline examines the science that speaks to the efficacy of the last consensus indication for angioplasty, the setting of an acute ST-elevation myocardial infarction (STEMI). Clinical science has rendered all other indications, by consensus, relative at best. But in the case of STEMI, the British guideline panel supports the consensus and concludes that angioplasty should be “offered” in a timely fashion.
I will not repeat my original essay here since it is only a click away. The exercise I display is how I would take this last consensus statement into a trusting, empathic patient-physician discourse. This is a hypothetical exercise to the extent that little in the way of clear thinking can be expected of a patient in the throes of a STEMI, and not much more of the patient’s caring community.
So all of us, we the people regardless of our credentials, need to consider and value the putative efficacy of angioplasty (with or without stenting) a priori. For me, personally, there is no value to be had rushing me from the “door to the balloon” regardless of the speed. You may not share this value for yourself, but my essay speaks to the upper limits of benefit you are seeking in the race to the putative cure by dissecting and displaying the data upon which the British guideline is based.
There is an informative science, most of which cannot deduce any benefit and that which deduces benefit finds the likelihood too remote for me to consider it worth my attempt. A hundred or more patients with STEMI would have to be rushed to the catheterization lab to perhaps benefit one (and to harm more than one).
Since STEMI is common and angioplasty is widely available, this exercise in informed medical decision making should be as widely discussed. It is the 21st century and clinical decisions should be based on “opinion and common practice” by default, never when there is a robust informative science.
Furthermore, if there is residual uncertainty (as is frequently the case), the patient should no longer feel constrained to ask, “What you do, Doc?” The query that reflects the trusting empathic patient-physician collaboration is “What would you do if you were me?” That is my thesis in writing this essay and 5 recent books.
However, I am not naïve; this is a thesis that some will take as an assault on interventional cardiology as opposed to a celebration of its enlightenment. Those are likely to be the patients who are certain they are alive today because of angioplasty and those they hold up as their saviors. Furthermore, the families of those who did not survive their STEMI despite angioplasty are comforted by the notion that they did the best they could but the attempt was overwhelmed by the magnitude of their loved one’s disease. This line of reasoning had comforted minions throughout the history of western medicine. Today it falters on the shores of refutation.
There is a not-for-profit organization, angioplasty.org, which announces that it is “The most popular angioplasty site on the net: A community of cardiologists and patients since 1997.”
Indeed the founding fathers include Andreas Gruentzig MD, the inventor of angioplasty, and John Abele, the founding CEO of Boston Scientific, an enterprise that has long purveyed the related devices. The Producer and Editor-in-Chief is Burt Cohen, a professional medical documentarian who counts some of the nation’s cardiology luminaries among his “Resources and Experts.”
Mr. Cohen posted a response to my THCB essay, which he titled “R.I.P. Angioplasty 1977-2013 – Really?” It is his attempt to defend
“…the fact that, according to the National Cardiovascular Data Registry (NCDR) 71% of the 600,000 angioplasties performed annually in the United States are done urgently: that is, for patients in the midst of a heart attack or acute coronary syndrome. Virtually every practitioner in the field of heart disease agrees that the gold standard treatment for ST-elevated Myocardial Infarction (STEMI) is angioplasty.”
I agree with this “fact.” It is the defense that is telling.
There is no argument that the science as outlined in my essay fails to provide support for this “fact.” The argument relates to the possibility that the science is either inadequate or missing the forest for the trees. There is no perfect study in this field or any other, particularly when one is trying to test a hypothesis such as angioplasty saves the lives of patients with STEMI; there is enormous inherent heterogeneity to be measured or overcome at every stage of the testing. The available science is reproducibly as good as it gets.
I don’t, and don’t want to sit on guidelines panels. I don’t, and don’t want to sit on the committees that define the indemnifiable. I want to urge my patient to feel empowered to ask, “How certain are you that…will benefit me and what is the basis for that degree of certainty?” I want to educate my patient so that they can actively listen to the answer.
When it comes to angioplasty with or without stenting for STEMI or any other manifestation of coronary artery (or carotid or renovascular) disease, I want my patient to understand that this is not a lottery. You are as likely, or nearly as likely, to do well without the procedure as with it and will be spared the down-side. If they are so educated, even if they value the “nearly” prospect that I discount for myself, I have served them well.
Nortin M. Hadler, MD MACP MACR FACOEM is a professor of Medicine and Microbiology at the University of North Carolina – Chapel Hill. While certified as a Diplomate of the American Boards of Internal Medicine, Rheumatology, Allergy & Immunology and Geriatrics, Hadler was also awarded an Established Investigatorship by the American Heart Association. His assaults on medicalization and overtreatment appear in many editorials and commentaries, as well as in 5 recent monographs: The Last Well Person (2004), Worried Sick (2008), Stabbed in the Back (2009), Rethinking Aging (2011), and most recently, The Citizen Patient (2013).