Let’s Disagree to Agree: the Not-So-Great Coronary Angioplasty Debate and a Patient’s Right to Speak

I read yesterday morning that I was now a party to “The Great Coronary Angioplasty Debate.” (Note to self: don’t look at Twitter before Sunday brunch.)

This all started a week ago, when Dr. Nortin Hadler posted an op-ed piece on The Health Care Blog, titled “The End of the Era of Coronary Angioplasty.” He opined that angioplasty was unnecessary in the setting of a major heart attack (a.k.a. STEMI) and might even worsen outcomes. His title and thesis was so over-the-top (intentionally so, I’m sure) that I felt obliged to pen a response to his very anti-stent article.

So now, he has posted a response to my response. I guess that’s a debate….

In any case, the fact is that emergency angioplasty (primary PCI) has been shown to save heart muscle and lives in all the trials and studies that have been done over the past two decades. These are numbers, hard facts, not a priori or conjecture. Yes, it must be done quickly, which is why every PCI-capable hospital in the U.S. has been working for years to get the “door-to-balloon” time down, to be able to mechanically reperfuse infarcted coronary arteries and stop a heart attack in its tracks. I even wrote a follow-up article, to answer questions that readers had posted, titled “Angioplasty, Stents or Fibrinolytic Therapy for Heart Attacks?”

Every guideline and recommendation from the U.S. to Europe to pretty much everywhere in the world has judged angioplasty and stenting to be a Class Ia recommendation for the treatment of STEMI. But don’t take my word for it. Read the “2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.”

To recap briefly: in the setting of stable non-emergency patients, there has been a healthy debate in interventional cardiology about the correct course of treatment: medical therapy, angioplasty or surgery? But in the setting of a major life-threatening heart attack, there really is no debate. The numbers tell the story: before the era of angioplasty, these serious myocardial infarctions carried a 30% mortality rate; today it’s less than 5%. So where’s the debate?

Well, Dr. Hadler’s subtitle is “Giving Patients the Right to Speak.” And here’s where I will disagree to agree.

I agree — completely — about the importance of the “patient’s right to speak.” At Angioplasty.Org, we’ve written about patient involvement, shared decision-making, the empowered patient. We even started a separate blog this year called, “The Activated Patient.” I wrote an extensive article last year, reporting on the whole issue of “Ad-Hoc Angioplasty,” and I think that Dr. Hadler would probably agree with our ideas on these topics. In short, we feel that patients should and need to be involved in their own healthcare decisions, and that patients who are will probably have better outcomes as well. So there is no debate there. We all agree.

But I also disagree, because in an emergency situation, how can it be possible to “discuss options’ with a patient, a patient who is in the throes of a life-threatening heart attack? Adrenaline is pumping, most likely morphine has been given to ease the pain — this patient is in no shape to discuss anything; this patient needs to be revascularized quickly, to save heart muscle and to save the patient’s life.

To use the concept of “a patient’s right to speak”, and tap into the world of patient advocacy, in the service of promoting a strategy that might ultimately do harm to patients (i.e. dissuading patients from emergency angioplasty) is something I strongly disagree with.

On a more specific and close-to-home note, I would like to correct a fact that Dr. Hadler details in his description of our web site, Angioplasty.Org.

Andreas Gruentzig, the inventor of percutaneous coronary angioplasty, was not a “founding father” of our site; I had the honor of knowing him and working with him, but he died in a tragic plane crash a dozen years before Angioplasty.Org existed, in fact several years before the World Wide Web existed. However, Dr. Richard K. Myler, who performed the first angioplasty in the U.S., was instrumental in our beginnings. Dr. Myler passed away two weeks ago and we are all saddened by this loss. But both Gruentzig and Myler and so many of the early pioneers were actually very conservative. Gruentzig initially thought that maybe 5% of patients with CAD could benefit from angioplasty. And both he and Myler were adamant about gathering data and outcomes to make sure what they were doing was a help to patients, not a harm.

But in the end, Dr. Hadler states that when having a serious heart attack, “You are as likely, or nearly as likely, to do well without the procedure as with it and will be spared the down-side.” This is not true, at least according to the data gathered to date. If you don’t receive the benefit of early and rapid revascularization in the setting of a STEMI, your heart muscle will be damaged. Assuming you survive, you will not regain the strength or quality of life you had previously. On that, there is no “Great Coronary Angioplasty Debate.”

Late update on Oct 22, 10:28am: In case anyone needs more convincing about the superiority of primary PCI in the setting of STEMI, read yesterday’s article by Eryn Brown in the L.A. Times: Kaiser to join L.A. County transfer network for heart attack care. Healthcare giant Kaiser finally joined in the network to get heart attack victims to a cath-PCI-capable hospital ASAP. Here’s the telling paragraphs:

Dr. Todd Sachs, medical director of operations for the Southern California Permanente Medical Group, said that before making the policy change, his group wanted more data showing that transferring patients was more effective than giving them medication…. “You could say we weren’t first to the table, but our goal isn’t to be first to the table,” he said. “Our goal is to give the best quality of care.”

In the 1990s hospitals typically gave such patients drugs, known as thrombolytics, to break up clots that cause heart attacks and restore blood flow to the heart muscle, said Dr. William French, who runs the cardiac catheterization lab at UCLA-Harbor Medical Center. But researchers discovered that patients had better results when they were treated initially with procedures such as angioplasty, in which doctors insert a catheter and balloon into blocked blood vessels to restore blood flow.

Like I said, there’s really no debate on this issue.