Observations: Too much angioplasty
The recent decision by former US president George W Bush to have a stent implanted, despite having no symptoms, has led to concerns about the benefits and potential harms of this procedure.
One leading US cardiologist has called the practice of routine testing in patients without symptoms leading to procedures that are not indicated as “American medicine at its worst.”
On bmj.com today, Aseem Malhotra, a cardiologist at the Royal Free Hospital in London, argues that stenting offers no more prognostic benefit than drugs for treating stable coronary artery disease - and asks was George W Bush aware of the potential harms?
The article is part of The BMJ’s Too Much Medicine campaign to help tackle the threat to health and the waste of money caused by unnecessary care.
Stents are small tubes used to unblock arteries that have become thickened by fatty deposits to improve blood flow to and from the heart.
But Dr Malhotra argues that “a multitude of robust randomised trials … has not showed any prognostic value in stenting for stable angina in addition to optimal medical therapy.”
Yet such practice continues to contribute to overspending in US healthcare; total spending is predicted to exceed a colossal $3.1 trillion next year, he writes.
For many doctors, the system contributes to overtreatment, he says, with pressures to “protect the service” or in “fee for service” models, where interventional cardiologists as well as hospitals are generously remunerated for undertaking many procedures.
Emotional and psychological factors, such as fear of untreated stenosis causing cardiac events, and pressure from patients who may not fully understand the complexity of coronary disease, can also influence decision making towards intervention, he adds.
“We should, however, proceed with cautious optimism,” he writes, referring to the dangers of “enthusiastically embracing a new technology, often fuelled by the manufacturer promoting the benefits of its product.”
So why did an asymptomatic and active former president receive a stent after a yearly “check-up” he asks? Did he know before agreeing that the procedure that carries a 1% risk of heart attack, stroke, or death?
He calls for “a greater appreciation among clinicians as well as patients that stenting for stable coronary disease has no prognostic benefit above medical therapy, would reduce unnecessary referrals, lessen anxieties, and help wind back the harms of “too much” angioplasty.”
Aseem Malhotra, Interventional Cardiology Specialist Registrar, Royal Free Hospital, London, UK
Tel: +44 (0)7786 075 842