In the June 23rd edition of The New York Times two articles stood juxtaposed under that title “Rethinking Cardiac Care.” Both articles demonstrate the uncertainty that is pervasive in medical thinking, while showing that our knee-jerk response to such uncertainty often is to over-treat by fixing a number (in the case of high blood pressure) or a blocked artery (in the case of stents), believing that we have helped the patient by utilizing such “thorough” treatment. What the articles do not discuss is how Medicare, through its payment structure and quality indicators, actually encourages us to endorse ineffective treatments that could be very harmful to our patients at a high cost to society.
One article discussed how cardiac stents are, in the vast majority of cases, no better than simple drug treatment in preventing poor outcomes such as heart attack and death in people with blocked heart arteries. Citing information of which we have been aware for many years, the authors accurately state that when heart tests (catheterizations) identify narrowed blood vessels that are then opened with stents, heart attack risk does not typically diminish. Why? Because heart attacks do not necessarily occur in blocked arteries, as counter-intuitive as that statement is. So we when do stress tests and catheterizations to discover blockages, and when our cardiologists save our lives (as so many of my patients tell me) by opening those arteries with stents, they may not be doing us any favors. In fact, they may be exposing us to substantial unnecessary risk by stenting us, as I describe in my book. While more studies are still pending, and while stenting does have a very important role in the context of helping people with active heart attacks, the true utilities of cardiac testing and stent placement will vary from patient to patient and situation to situation. Its over-use is endemic of an illusion inscribed in the very ethos of medical thinking, and endorsed by Medicare and its payment structure, that finding and fixing abnormalities in an elderly body leads to better outcomes. But in the process many patients are exposed to unnecessary harm, certain doctors are enriched, Medicare pays unnecessary millions of dollars, and more proven treatments for heart disease (exercise, nutrition, certain drugs) are not prescribed or paid for. Patients think their lives are saved, and often are told so by the doctors performing the procedure, but in fact they may have done better on some inexpensive medicines and an exercise regime without having to expose their bodies to very profound risk.
The second article discussed optimal blood pressure in the elderly, which is something that is very variable, age dependent, and largely unknown, but which is delineated by a very strict Medicare guideline that diverges from everything we know medically. We will discuss that in our next blog.