LifeCare Chiropractic

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PCI

Common Heart Treatments Increase Heart Disease??

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You follow your cardiologist’s advice, thinking it will protect you in the long run.  But what if this is not the case?

It will come to no surprise for regular readers of my blog that I think that lifestyle changes are the ONLY answer for heart disease.  Unfortunately, many patients opt not to make the right changes, or worse–these changes are not even discussed with patients because of a lack of knowledge on the part of the provider.

This particular study looks at outcomes of medical treatment (i.e. drugs), coronary angioplasty (PCI) or open heart surgery (CABG) ten years later.  Here’s the disturbing findings after following 611 patients who had CABG, PCI or standard medical therapy (MT=drugs):

  • 10-year rates of needing additional invasive procedures (revascularizations) were 7.4% with CABG, 41.9% with PCI, and 39.4% with MT.
  • Those in the drug only group had a 235% higher risk of future cardiac events (including deaths) than in the CABG group.
  • Those in the PCI group had a 185% higher risk of future cardiac events than in the CABG group.
  • 10-year rates of freedom from angina were 64% with CABG, 59% with PCI, and 43% with MT (P<0.001).

The bottom line?  Medical treatment or PCI actually INCREASED the risk of the need for more stents, heart attacks and / or cardiac death.

Wow.  I know that it SOUNDS like doing procedures is a good thing and it all seems well and dandy on paper, but when translated to the patient the outcomes just don’t work out.  So it boils down to having your sternum cracked open and some blood vessels taken from another area of your body to replace the disease ones that are needed to get nutrients and oxygen to your heart.

Or…

Eat better / stress less / exercise.  Hmmm…tough decision…

Does Your Cardiologist Perform this Invasive Procedure?

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If you have any interactions with a cardiologist, this is a must read.  And read VERY carefully.

Percutaneous coronary intervention (PCI) is the procedure where a stent is (almost always) placed into a coronary artery.  Most know this as coronary angioplasty.  This procedure largely did not even exist a decade ago (it began to blossom in the late 80’s, but it seems to me like the past decade has seen major increases).   It has created an entire field within cardiology called interventional cardiology.

It has been established that coronary angioplasty for non-emergency chest pain really does nothing but makes the patient feel better temporarily, until they actually have a heart attack sometime in the near future.  To make this a little more problematic, this is NOT a cheap procedure (runs around $35K) and has its list of side effects, including death.

But does your cardiologist know this?  In this particular study, researchers asked this very same question of a group of 27 cardiologists (10 interventional and 17 referring).  Here’s what they found:

  • 63% of cardiologists surveyed agreed that PCI is ONLY good for symptom relief.  Symptom relief only.
  • Almost 3/4 of patients felt that, without the PCI, they would definitely suffer a heart attack in the next 5 years
  • 88% of patients, however, mistakenly believed this procedure would prevent a future heart .  Talk about a disconnect!
  • The real deeper problem here, however, is that, despite the fact that this procedure would only manage symptoms and not really fix anything, 43% of cardiologists would STILL PERFORM THE PROCEDURE!!

Yes–almost half of the cardiologist would still perform a $35,000 procdure with death as a potential side effect that does little other than help with chest pain.

And your insurance will gladly pay for it.  No wonder our system is so screwed up!

Coronary Stents and Reality; Did Your Cardiologist Come Clean?

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Heart attack risks

Heart stents.  Coronary Stents.  Angioplasty.  Angiogram.  Percutaneous Coronary Intervention (PCI).  Regardless of what you call it, over a half MILLION of them are done per year at a cost of around $18,000 each.

Sounds great.  After all, we’re saving lives with these remarkable procedures that are far, far easier on the patient then cracking open the sternum and replumbing the coronary arteries.

Well yes.  And no.

For emergency procedures, the research is pretty positive.  The sooner you can get this procedure done in the middle of a heart attack, the better the outcomes.  That’s where the clarity ends.  In general, it is pretty well accepted (in the research, but not among cardiologists who do these procedures) that for non-emergency, elective procedures, the data on PCI crashes.  To the tune of about 50% of them being done inappropriately.

These are some serious numbers, serious dollars and serious risks to the patients.  And just in case the patient makes it through the procedure, they have usually earned a year or so on blood thinners.  In coming years, the risk of the stent closing back up again is always brewing in the background.

But all of this is ok, because before you receive ANY medical care, there is something called informed consent.  Under informed consent, it is the obligation of a physician to explain the procedure being done, the risks of the procedure, the risk of NOT getting the procedure and the alternatives.  It would make sense that, as the procedure becomes more invasive, the obligation to fully inform the patient should grow as well.

After all, how can you, as the patient, truly make a decision about a procedure this important (or not) without being fully informed??  You really can not.

Which brings us to this particular study.  In it, researchers reviewed We performed recorded 59 conversations by 23 cardiologists among adults with known or suspected stable coronary disease at outpatient cardiology practices.  These conversations were evaluated for 7 accepted elements of informed constent when it comes to helping the patient make the decision to undergo angiography and possible stenting.  Here’s what they found:

  • A paltry TWO (3%) conversations included all 7 elements of informed decision making.
  • Another eight conversations (14%) met a more limited definition of procedure, alternatives, and risks.

When the cardiologist was more forthcoming and honest about expectations of the procedure, the outcome of the visit was drastically different:

  • If the cardiologist discussed clincially viable alternatives (i.e. medications, lifestyle changes, no treatment–the term for this in informed consent is “uncertainty “), the patient was 20.5 TIMES less likely to choose the procedure.
  • If the cardiologist discussed the patient’s role in deciding about having the procedure done, they were 530% less likely to undergo PCI.
  • If there was an exploration of alternatives the patient was 950% less likely to choose PCI.
  • Neither the presence of chest pain (angina) nor severity of symptoms were associated with choosing angiography and possible PCI.
  •  Overall, better informed patients were 320% less likely to choose angiography and possible PCI.

Granted, this was a small subset of practicing cardiologists and maybe the bulk of cardiology practices do not follow the practices seen in this study.  But, given how rushed many specialist offices tend to be, I’m afraid this is standard.

Overall, though, I think this reflects the disconnect between what patients perceive and what the reality is of the medical procedures that are performed with a high degree of regularity in modern medicine.  The list of procedures and medications that have shown little benefit in the medical research but continue to be used is quite long.

And this is heart disease.  Almost entirely preventable!  For a long time now we’ve known that lifestyle changes produce better outcomes than PCI and yet this procedure is still done on an elective hundreds of thousands of times per year.

So, if YOU had a stent put in, do you feel that your cardiologist fully educated you on the risks, benefits and alternatives?

Preventing Heart Disease: Do Cardiologists Help?

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cardiologists and heart disease
pixdesign123/Dollar Photo Club

Don’t get me wrong. I don’t inherently have a problem with cardiologists. But, for heart disease to be almost entirely preventable and remain the #1 killer in the industrialized world, we’ve absolutely dropped the ball.

I just don’t see any excuse for a clearly preventable disease to be the #1 killer.

And I cannot accept the fact that medicine is doing better at preventing cardiac deaths (largely due to technology saving lives when the fecal matter hits the fan).  We are doing absolutely awful at preventing cardiovascular disease.

This is in the face of a truly massive amount of evidence on how to prevent cardiovascular disease using lifestyle.  Maybe cardiologists are really spending the time needed to educate their patients about the best lifestyles to drastically lower the risk of having a heart attack or stroke and patients just aren’t listening.  Or maybe mainstream medicine is so caught up in procedures and prescriptions that they have let lifestyle advice to patients fall to the wayside.

The answer likely lies somewhere in between.  I think society is just as heavily to blame because we have created an illusion where medicine actually fixes things.  You do not need to exercise or change your diet because the drug you are taking has lowered your blood pressure, stopped your irregular heartbeat or lowered your cholesterol.  And when that doesn’t work you can go in for a quick in-and-out Roto-rooter procedure and you’re good to go.

If society really knew just how little these approaches really help things might change.  And I think that the foundation for this perceptual change needs to begin with the cardiologists.  It is a profession that needs to stand up and work as hard as possible to destroy itself.

While destroying itself sounds a wee bit, well…self-destructive, this is the way our office functions when it comes to chiropractic care.  I tell patients that it is our job to destroy the practice by pushing for patients to become more active, eat right, treat injuries appropriately and engage in positive musculoskeletal behaviors like yoga.

While it don’t think it will ever happen, it’s still the attitude that we maintain every day.

Cardiologists need to hop on board with this attitude and take a good hard look at what kind of information they are giving their patients.  It would be hard for any professional to look at a client, customer or patient and tell them straight on that he or she has little to offer.

Certainly cardiologists have procedures they can offer to patients.  And, at the end of it all, there is absolutely no doubt that cardiologists are amazing at saving lives.  But they just seem to have a hard time diverting current patients from needing that end-of-the-line lifesaving procedure.

I thought all of this would be a good primer for this particular study.  In it, researchers looked at cardiac outcomes during 2 large, national cardiology conferences over the course of 9 years.  They then compared these same outcomes to 3 weeks before and 3 weeks after the conferences to see how rates compared.

One would think that, with hospital cardiologists being out of town during these big conferences, it would spell trouble for patients who have heart disease during these time periods.

But here’s what they found:

  • In teaching hospitals, risk of high risk patients dying from heart failure during the meeting times was lower (17.5%  vs 24.8%).
  • Deaths from cardiac arrest were also lower during meeting times (59.1% vs 69.4% ).
  • Rates of percutaneous coronary intervention (PCI–the procedure used to put stents in blocked arteries) were, as expected, lower during meetings (20.8% vs 28.2%;).  However, lower rates of PCI did not affect a high-risk heart attack patient’s chance of dying (39.2%  vs 38.5%–in other words, despite not having cardiologists to do these procedures, no one was dying any faster).
  • On the flipside, in nonteaching hospitals, there was no difference in the risk of dying or having a procedure (both high- and low-risk patients ).
  • There was also no higher risk of dying in teaching hospitals for low-risk patients.

Wow.

Not sure that there’s any other way to look at this other than saying that there is a chance that teaching hospitals may be doing slightly more harm than good when it comes to the cardiovascular departments.

As an example, it is estimated that half of the non-emergency cardiac stenting procedures are unnecessary.  Considering that these procedures have risks associated with them, it would not be a surprise to see less procedures leading to less deaths.

In an area that has several teaching hospitals, I can assure you that the perception of these teaching hospitals by patients is very high and many will bend over backwards trying to get into them for their problems.

That just may not always be the best idea.  The bottom line is that, even in prestigous teaching hospitals, your cardiovascular health may be better off where it has always been–inside you.

 

CARDIAC STENT VS OPEN HEART SURGERY – (07-16-04)

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Percutaneous Coronary Intervention Results in Acute Increases in Oxidized Phospholipids and Lipoprotein(a)

While there is no question that, should I have a choice between PCI and open heart surgery, I would pick PCI anyday. But this procedure is done on many patients as a screening tool with chest pain. Many negative tests are done without thought to the long term consequences other than healing of the incision.

This study finds that there is a long term elevation of oxidized LDL (remember–LDL cannot damage our vessels until it gets damaged via oxidation) after PCI. This might be a willing trade off to the patient that avoided open heart surgery. But to the patient that was scoped to “rule out” obstructive lesions, this is not a good trade off. Maybe these findings will push a greater use of the non-invasive ultra fast CT, which does a nice job of ruling out cardiac involvement in patients with chest pain. Circulation — Abstracts: Tsimikas et al. 109 (25): 3164 –

Read entire article here

COMPARISON OF LONG TERM OUTCOMES AMONG PATIENTS – (08-28-06)

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Comparison of Long-Term (Seven Year) Outcomes Among Patients Undergoing Percutaneous Coronary Revascularization With Versus Without Stenting.

This is one I can’t hammer on long enough. We have created a huge and profitable subsection of cardiology that, quite frankly, does nothing to change long term outcomes in patients. Cardiologists are getting rich on PCI procedures that, from several studies now, have failed to show a long term benefit. I could not begin to calculate the costs associated with these procedures collectively, but I can guarantee that lifestyle changes would be a little cheaper.

Read entire article here

WAS THAT CARDIAC STENT REALLY NEEDED?

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Had a cardiac stent put in?  Was it really needed?  Basically, it’s a toss up.  50 / 50.

I’ve written before about the reality of this procedure, which has some pretty severe limitations.  Many patients mistakenly believes that percutaneous cardiac intervention (PCI or angioplasty) will prevent them from having a heart attack in the future.  Many doctors do not discourage this opinion, although it is not true in many cases.

About 50% of the time, the only expected outcome of this procedure is angina / chest pain relief.  Sounds good, until you realize that the procedure involves sticking a scope up into your heart itself to take a peek around and has significant risks AND earns you 6 months to a year of Plavix or Coumidin (which carry risks as well..).

Worse, the procedure costs some $50K or more.  Talk about a waste of healthcare dollars!  As a chiropractor constantly dealing with insurance companies wringing our reimbursements down, in recent examples, 50% lower to save money on a fraction of the costs in healthcare, I find it sickening to see this type of abuse that is allowed to occur virtually unchecked. 

This particular editorial laments the waste and abuse in the cardiology realm with this procedure.  Despite strong research suggesting that 50% of the procedures would have been better treated with medications (a topic we obviously won’t get into here…), there has been no behavioral change among most cardiologists.

So, for those of you that think that the typical cardiologist has their nose stuck in medical journals to keep up with the latest research, you might want to rethink that position.  Or worse, they are aware of the research and choose to ignore it for financial gain.  Take your pick.  Either way, it’s not too pretty.

For me, I’d opt for strong lifestyle changes at this point.  Cheaper.  Cuts across much more than just heart disease.  No long term damage (unless you call improved physiology damaging).  And certainly safer.  A no brainer to me.

Read more…

GETTING A CARDIAC STENT? CHECK THIS FIRST…

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Regardless of whether you’re on the cath table just starting to fade away from the anesthesia or are reading this from home, inflammation is a major, massive player in heart disease.  We’ve spent so much time focusing on cholesterol levels, mainly because we had a drug that could lower this value so we fit the disease risk factors to the drug that could control that risk factor.  Only recently has inflammation (usually as measured with hsCRP) been looked at as a risk factor.

Percutaneous coronary intervention (PCI) is the procedure in which a cardiologist pokes a camera into your coronary arteries to look at how healthy they appear.  If there is a problem, the common answer is to place a stent in a blocked artery to make sure that blood continues to flow through this artery to feed the heart.  The big problem with this procedure is that these stents have a tendency to plug back up again (restenosis).  Two schools of thought exist– the use of bare metal stents or the use of drug eluting stents to lower the risk of restenosis.  In this particular study, researchers determined that the inflammation levels were a major determinant in which a bare metal stent or a drug eluting one should be used.

Less simplify this.  Manage your inflammation long before you need a stent and the decision won’t be there to make.  Exercise, live an anti-diabetic lifestyle, stress less, add a multivitamin, D and mixed tocopherols (Vit E) as well as fix any silent sources of inflammation like poor oral health, poor gut health or food allergies.

http://www.sciencedirect.com/science/article/pii/S0002914911003869