Is Heart Surgery Worth It?

[Guest guest]

This is being posted to show that allopathic treatments are usually

ineffective. It is not to promote allopathic drugs over surgery and other such

nonsense. In medicine there usually is a continual introduction of the newest,

latest, whiz bang " miracle treatment " until it is proven false 20, 30 or 40

years later, and all the while the continuing introduction of the newer later

" miracle " treatments. If any were worth anything they would stay as true

effective treatments that would build up into a base of effective treatment and

disease would decrease, which we all know has NOT been the case. It more closely

resembles a con game approach to keep the suckers buying what they have to sell.

F.

 

 

http://.businessweek.com/magazine/content/05_29/b3943037_mz011.htm

 

 

 

Is Heart Surgery Worth It?

 

 

Physicians are questioning whether bypasses and angioplasties

necessarily prolong patients' lives.

 

You start breathing hard after climbing stairs, and your chest hurts.

You go to your doctor. Scans reveal that arteries feeding your heart

are severely narrowed. Your doctor sends you to the hospital for

coronary bypass surgery or angioplasty to restore the blood flow to

your heart. Despite the trauma of surgery, you're glad the blockage

was caught in time, saving you from a potentially fatal heart attack.

 

There's just one problem with this happy tale of modern medicine:

More and more doctors are questioning whether such heart procedures

are actually extending patients' lives. One of them, Dr. Nortin M.

Hadler, professor of medicine at the University of North Carolina at

Chapel Hill and author of The Last Well Person, is urging the U.S.

medical Establishment to rethink its most basic precepts of

cardiovascular care. Bypass surgery in particular, he says,

" should have been relegated to the archives 15 years ago. "

 

That is an extreme view that is disputed by cardiac surgeons. " The

reason thousands and thousands of bypass surgeries have been done is

that [the procedure] is successful, " says Dr. Timothy J. Gardner,

co-editor of Operative Cardiac Surgery and a cardiothoracic surgeon at

Christiana Care Health System in Wilmington, Del.

 

Nevertheless, the data from clinical trials are clear: Except in a

minority of patients with severe disease, bypass operations don't

prolong life or prevent future heart attacks. Nor does angioplasty, in

which narrowed vessels are expanded and then, typically, propped open

with metal tubes called stents.

 

" People often believe that having these procedures fixes the problem,

as if a plumber came in and fixed the plumbing with a new piece of

pipe, " explains Dr. L. David Hillis, professor of cardiology at the

University of Texas Southwestern Medical School. " But it fundamentally

doesn't fix the problem. "

 

With doctors doing about 400,000 bypass surgeries and 1 million

angioplasties a year -- part of a heart-surgery industry worth an

estimated $100 billion a year -- the question of whether these

operations are overused has enormous medical and economic

implications. " It is one of the major issues in cardiology right now, "

says Dr. David Waters, chief of cardiology at the University of

California at San Francisco.

 

It is also part of a far broader problem -- what some health-care

experts call the medicalization of life. " None of us will live long

without headache, backache, heartache, heartburn, diarrhea,

constipation, sadness, malaise, or other symptoms of some kind, "

argues Hadler. Yet under relentless bombardment by messages from the

pharmaceutical and health-care industries, Americans increasingly

believe that these symptoms -- and many others -- are conditions that

can and should be cured. " We have an image of ourselves as invincible

and powerful and able to overcome all odds, " Hadler says. " And the lay

press is too quick to talk about the latest widget and gizmo

without asking what it is and does it work. "

 

HIGHER COST, BIGGER RISK

 

Indeed, there is compelling evidence that more health care and more

aggressive treatment across the complete spectrum of illnesses is not

necessarily better. When Dr. Elliott S. Fisher, professor of medicine

at Dartmouth Medical School, first looked at regional differences in

health-care spending in the U.S., he assumed that people in areas with

lower expenditures would have worse health than people in regions

where spending was 1 1/2 to 2 times as high because they were failing

to receive needed care. It turned out that the opposite was true.

 

" Patients have a substantial increased risk of death if cared for in

the high-cost systems, " he says. Why? For one thing, additional doctor

visits and testing often lead to unnecessary procedures and

hospitalizations, which carry risks. " My data suggest that we are

wasting 30% of health-care spending on stuff with no benefit and

perhaps causing harm, " says Fisher.

 

International comparisons support his reasoning. The U.S. spends 2

1/2 times as much as any other country per person on health care, but

that doesn't translate into better outcomes, according to studies that

compare such indicators as fatality rates after a heart attack and

length of survival after a kidney transplant. That suggests that " the

investment in health care in the U.S. is just not paying off, " says

Gerard Anderson, director of the Center for Hospital Finance &

Management at Johns Hopkins Bloomberg School of Public Health and

co-author of a 2004 study that looked at 21 different health-

quality indicators in five nations.

 

Similar comparisons can help pinpoint dubious treatments. The classic

case: tonsillectomy. In the early 1970s, Dr. John E. Wennberg, now

director of the Center for Evaluative Clinical Sciences at Dartmouth

Medical School, showed that some hospitals removed tonsils 10 times as

often as others. But the children in areas with low rates weren't

worse off, so the operation fell out of favor.

 

More recently, Dr. James N. Weinstein, chair of orthopedic surgery at

Dartmouth-Hitchcock Medical Center, found that people with back pain

are up to 20 times as likely to have back surgery in some parts of the

country as in others. Yet it's not clear that they do better as a

result. Weinstein is comparing the outcomes in patients who get

different treatments, from rest and physical therapy to spinal fusion.

Meanwhile, he says, " billions of dollars are being spent without good

information. "

 

 

This is of obvious concern to those who pay for health care, from the

government to private insurers, which are struggling to better

balance costs and benefits. And nowhere are the financial and health

stakes higher than in the area of cardiac surgery. U.S. patients and

insurers will spend $3.4 billion this year on drug-coated stents from

suppliers Boston Scientific Corp. (BSX ) and Johnson & Johnson (JNJ ),

according to Citigroup.

 

At many hospitals, cardiac units have become major profit centers.

" We've shown that it is a lucrative area for hospitals, " says Paul B.

Ginsburg, president of the Center for Studying Health System Change.

 

But are heart procedures always the best path for patients who

currently get them?

 

The answer seems to be no. As Hadler describes in his book, data from

bypass-surgery clinical trials in the late 1970s show that the

procedure extends life or prevents heart attacks only in a small

percentage of patients -- those with severe disease. More recent

trials with angioplasty show it reduces deaths mainly just in

emergencies. " For people in the throes of heart attacks,

opening the artery definitely prolongs life, " says UCSF's Waters.

 

Not so for patients with stable chronic disease. " The overwhelming

number of heart procedures done these days do not affect patients'

life span at all, " says Hillis.

 

The latest thinking on heart attacks may explain why not. In the

traditional view, the slow accumulation of plaque inside arteries

gradually narrows the vessels. Reduced blood flow causes chest pain,

or angina. Eventually the arteries are blocked, bringing on heart

attacks. Newer evidence, however, pins the blame not on this gradual

narrowing but on unstable plaque that breaks off and causes clots. The

clots are what obstruct the arteries, causing the heart attacks --

which is why so many such events are unexpected and why " there is no

evidence that opening chronically narrowed arteries

reduces the risk of heart attack, " says Waters.

 

DIET AND LIFESTYLE

 

A better way to lower heart-attack risk is to fight the unstable

plaque with aggressive cholesterol-reducing drug therapy, diet, and

lifestyle changes, many cardiac physicians say. That can be a tough

sell to patients who want a quick fix, says Hillis. " Medical therapy

is just not as sexy as doing a procedure, " he explains. " The ssumption

our society makes is that the more aggressive your medical care is,

the better it is. It's not true. But if I explain to a patient why he

doesn't need surgery, 9 times out of 10 he will go across town

and find someone who will do the procedure. "

 

The surgeries do relieve angina symptoms -- and for some doctors

that's a slam dunk. Emory University cardiologist Dr. Robert A.

Guyton, co-chair of the American College of Cardiology and the

American Heart Assn. committee that wrote the current bypass-surgery

guidelines, points to patients disabled by pain and shortness of

breath who, a month after bypass surgery, " are walking around as

healthy as you or I, " he says. " To say the whole operation

ought to be scrapped is nuts. " Similarly, angioplasty eases the often

crippling pain of angina. " There is quite a lot of good evidence for

symptom relief, " says Dr. Robert Henderson, a cardiologist at

Nottingham City Hospital in Britain and co-investigator for a key

angioplasty clinical trial.

 

Critics such as Hadler, on the other hand, emphasize the risks. Not

only is there a 1% to 2% chance of dying during a bypass operation, he

explains, there is a high risk of complications and a 40% chance of

cognitive deficits.

 

The healthy, active post-surgery patient is an " urban legend, " he

says. " An alarming number never return to the workforce or describe

themselves as well again. "

 

Recent studies even raise questions about whether surgery causes the

symptom relief. In June, Harvard Medical School associate professor

of medicine Dr. Roger J. Laham reported on follow-up results of a

randomized trial looking at laser surgery to improve blood flow.

Patients who got the surgery had significantly less pain and improved

heart function. But so did patients who had a sham operation -- the

equivalent of a placebo.

 

After 30 months the placebo effect was still there. Scans and other

tests showed physiological gains in blood flow among only those who

thought they had been operated on. A similar large placebo effect

might explain " most of the benefits that we've seen so far with

balloon angioplasty and bypass surgery, " Laham says.

 

There are also fresh concerns about the safety of drug-coated stents,

now widely used in angioplasty. When doctors first tried to open

clogged arteries with a balloon, they found that arteries soon closed

again. So they began inserting metal mesh stents to hold them open.

When arteries continued to clog up again, companies devised stents

impregnated with drugs that slow the growth of cells, reducing chances

that patients would have to have their arteries opened again.

 

First approved in April, 2003, drug-coated stents account for 88% of

the stents used in the U.S. But when pathologist Dr. Renu Virmani,

medical director of CVPath, a research service of the International

Registry of Pathology, examined the hearts or heart vessels of 39

patients who died after getting the new stents, she found clots in 11

cases that developed more than 30 days after the procedure. The sample

is small, and it's not clear that the clots caused the deaths. But

it's a big jump from her experience with patients who died after

getting bare-metal stents. Just 12.5% of them had late-developing

clots.

 

What worries some doctors is that people getting the new stents might

have a higher risk of clots, which then could cause heart attacks more

than a month after the procedure. " Out of 100 patients who get a

drug-coated stent vs. a bare-metal stent, maybe 10 will avoid a repeat

procedure, " says Dr. Eric J. Topol, chief of cardiology at the

Cleveland Clinic Foundation. " But how many will wind up with a heart

attack or death? Maybe one in 1,000? We just don't have that nailed

down yet. " Drug-coated stentmakers Boston Scientific and Johnson &

Johnson say their clinical trials show no such increased risk of

late-developing clots.

 

Cardiac surgeons readily admit there are big unanswered questions.

" We can handle the criticisms, and we should be accountable, " says

cardiothoracic surgeon Gardner. " But there is plenty of hard work

going on to try to determine the appropriate patients for whom such

treatments are necessary. "

 

There are also large clinical trials under way comparing surgery with

cholesterol- reducing drugs and other medical treatment, which will

provide better answers. If the trials show no benefit to surgery

compared to medicine, " it will be a serious challenge to the

coronary-intervention industry, " says Dr. Robert H. Jones,

distinguished professor of cardiothoracic surgery at Duke University

Medical Center. His prediction? " I'm a surgeon, so I think surgery

will hold up. "

 

The answers still may not be definitive, however, because medicine

continues to advance. " Every time these studies come out and show that

revascularization [improving blood flow] doesn't do much,

cardiologists say: 'Well, that study was started four years ago, and

now we have shinier stents, and the results are better, " ' notes UCSF's

Waters. " But medical therapy [with drugs] is getting much, much

better, too. " Harvard's Laham suggests that as many as 400,000 of the

angioplasties done in the U.S. each year may be medically unwarranted.

" I'm sure we are way overtreating our patients, " he says.

 

Some scientists argue that the rational solution is to let patients

decide for themselves. But that requires providing detailed

information about the risks and benefits of medical procedures, such

as coronary surgery -- including the unknowns. In trials where one

group gets the information and the other group receives no special

attention, the well-informed patients opt for more invasive,

aggressive approaches 23% less often, on average, than the other

group.

 

Without this full information, " patients typically don't understand

that they have options, and even if they do, they often wildly

exaggerate the benefits of surgery and wildly minimize the chances of

harm, " says Annette M. Cormier O'Connor, clinical epidemiologist at

Ottawa Health Research Institute and a leader in this field of

so-called decision aids.

 

It's a model approach for medicine in general. As Hadler argues, the

exaggeration regarding benefits goes far beyond heart surgery. Too

many common conditions are viewed as diseases needing treatment, and

too many treatments of uncertain benefit are used too often. " What

Hadler does is question the soundness of that thinking in a very

profound way, " says Dr. Glenn D. Pomerantz, senior vice-president for

global innovation at Cigna (CI ). Hadler hopes that enlightening

people about the limitations of medicine will help them worry less and

stay well longer. It also could help cure an ailing health-care

system, making it more rational. In the end, few doctors

will object to the basic prescription: Avoid drastic procedures that

probably won't help and might actually do harm.